Metastatic Breast Cancer
UNDERSTAND METATATIC BREAST CANCER
(16) How is chemotherapy given?
“Believe in yourself! Have faith in your abilities! Without a humble but reasonable confidence in your own powersyou cannot be successful or happy.”
- Norman Vincent Peale
This 3D medical animation about chemotherapy depicts normal cell division, apoptosis, tumor cell formation,tumor development, and angiogenesis of a tumor. It describes the cause of tumor cell formation at the genetic level with DNA, and metastasis through blood and lymph vessels. This animation covers the various effects of chemotherapy: cancer cell death, tumor death, destruction of normal cells and tissue. It also covers the side effects associated with chemotherapy treatments. Also described are related treatments, such as, radiation, pills, capsules, liquids, intravenous injections, surgical procedures, catheterization, CSF injection, wafter placement, and schedule of treatments.
Oncologists give chemotherapy in different ways, depending on the location of your metastases and the drugs that your oncologist gives you. The four most common methods are: intravenous, oral, intramuscular, and intrathecal.
(17) Metastatic Breast Cancer
What are ports and vascular access devices? Do I need one?
Vascular access devices (VADs, central venous catheters, ports) can make it easier and safer for you to get your treatment. They are not always necessary, but, if you are like most chemotherapy patients, once you have one, you will like it.
Intravenous chemotherapy and repeated blood draws can make your veins fragile. It often becomes hard for the nurse to find your vein. This can be very stressful and uncomfortable for you. If some chemotherapy drugs leak out of a fragile vein, they can damage your soft tissues. A VAD is a special thin tube (catheter) placed under the skin and inserted into a large vein in your chest. This is an outpatient procedure. A surgeon or radiologist will thread the catheter through a vein in your chest, or sometimes your arm, until it reaches a large vein near the heart. The catheter may be left in place for a number of months or years until it is no longer needed.
Complications are rare, but as with any operation, no matter how minor, complications are possible.
• Bleeding. This may occur when the catheter is inserted into the vein.
• Collapsed lung (pneumothorax). The risk of a collapsed lung varies with the skill of the person inserting the catheter and the site of placement. It is most likely to happen during placement of a catheter in the chest, although the risk is still small.
• Infection. This risk is present for as long as the catheter is in your body. It may require treatment with antibiotics in the hospital or removal of the catheter.
• Blockage or kinking of the catheter. A kinked or blocked catheter may need to be repositioned or replaced. Regular flushing of the catheter helps reduce blockage.
• Pain. You may experience pain at the place where the catheter is inserted or where it lies under your skin. This usually disappears a few days after the catheter has been in.
• Shifting of the catheter. A catheter that has moved out of place can sometimes be repositioned, but if this does not work, it must be replaced.
There are several different types of VADs. They are: Implantable port-a hollow round disk, about the size of a quarter, is placed under the skin, usually on the chest wall under the collarbone. To access the device, the nurse inserts a special needle through the skin into the port. If this hurts you, she can apply a numbing cream to the skin before she inserts the needle. A nurse must flush the device once a month to prevent it from clotting. No other care is required between treatments. Since this device is completely under the skin, you can shower and bathe with no worries.
Rather than being buried under the skin, the external catheter (Hickman or PICC line) tube exits the chest wall, usually under the collarbone. These catheters require frequent flushing and dressings. Your nurse will teach you how to change this dressing and care for the catheter. Since the end of the catheter is exposed, there is a slightly higher risk of infection than with the implantable catheter, and you will need to take special precautions when you shower or bathe. External PICC lines (peripherally inserted central catheter) are useful for short-term use or as a temporary measure until your doctor can have an implantable port placed.
Long-term external catheters (Hickman) are useful when giving chemotherapy continually or in patients who are “needle phobic” and unable to tolerate the needle sticks required to access an implantable port. In addition to their use in administering chemotherapy, you can get IV fluids, antibiotics, bisphosphonates, and blood products through the VAD. You can usually get blood drawn from the port, so you will be able to avoid frequent needle sticks for blood tests.
Do I have a choice of how I want to get my chemotherapy?
Chemotherapy is usually given in your veins, but sometimes it can be taken by mouth or as an intramuscular injection. You usually do not have a choice as to how it is given. Very few chemotherapeutic drugs are available as pills. Your doctor will pick the best chemotherapy for you based on where your cancer metastases are, your overall medical condition, and past treatment. People usually think that pills have fewer side effects than intravenous treatment, but this is not always the case. In fact, it is sometimes easier to control the dose and the side effects of intravenous chemotherapy. The side effects of chemotherapy depend on the properties of the drug, not on how you take it. Today, capecitabine is the most frequently used oral chemotherapeutic agent in treating breast cancer. Your oncologist decides how many pills you should take based on your height and weight. You usually take capecitabine twice a day for 2 weeks of a 3-week cycle, but your doctor may decide some other frequency is better for you.
The side effects of chemotherapy depend on the properties of the drug, not on how you take it.
What is a chemotherapy cycle?
Oncologists give chemotherapy according to a particular schedule that is based on the type of cancer being treated and the particular drugs being used. Chemotherapy may be given daily, weekly, every 2 to 3 weeks, or monthly. These treatment days are followed by rest days to allow your body time to recover from the effects of chemotherapy. This schedule of treatment and rest days is a cycle. There usually is no choice on the interval or for how many days of the cycle you will receive chemotherapy. Your oncologist will decide how many cycles of chemotherapy to give you based on how well your cancer responds to treatment, and on the side effects that you experience.
They may give it for a set number of cycles, but when treating metastatic breast cancer, oncologists usually continue treatment as long as it is working.
How will the doctors determine if the chemotherapy is working?
It usually takes two or three cycles of chemotherapy before your oncologist will know if it is working. After two or three cycles, your oncologist will repeat your scans to see if your metastases have gotten bigger or smaller. If there are new metastases or the ones that you have now are bigger, your oncologist will stop the treatment that you are taking, and discuss alternative forms of treatment with you. It does not make any sense to continue with a treatment regimen that is not working. You and your oncologist should be thrilled if the size and number of your metastases is smaller, but you should also be pleased if your cancer has not gotten any worse. Without treatment, metastatic breast cancer progresses, and, after a couple of months, if it is stable, it is probably because the chemotherapy has stopped it from growing. It is quite possible that there will be less cancer the next time your doctor repeats the scans.
“Stable or improved disease” is the definition of success that you and your oncologist should use to assess how well the chemotherapy is working. It sometimes takes a couple of months to see this, and that is why you have to wait before you repeat the scans. However, if it is obvious from your doctor’s examination that the cancer is growing at a fast pace, even after one cycle therapy, there is probably no reason to continue it. You or your oncologist might also stop the chemotherapy if you are It is essential that you understand how your oncologist will determine if the chemotherapy is working. You should know when the doctor will make this assessment, and how. It may not always be necessary to do a scan. If, for example, your doctor can feel an enlarged lymph node in your neck, she will measure this with a ruler each time you come for a visit. If you have cancer in your liver, your liver blood tests may be elevated, and your doctor can follow these to know if you are responding to treatment.
Even in these situations, your oncologist will probably want to repeat scans from time to time, so that she can more fully assess your response to chemotherapy. In addition to measuring the amount and size of your metastases, your oncologist may also use your symptoms to know if the chemotherapy is working. If the chemotherapy makes you feel better, this is usually a sign that it is working. Good clinical signs that the chemotherapy is working include pain that improves with chemotherapy, a poor appetite or weight loss that is now better, or feeling less tired.
In summary, the definition of “working” is when the cancer is not getting any worse. Oncologists generally continue giving chemotherapy as long as it is working, or until you have unacceptable side effects. You should expect your doctor to assess this every two to three cycles of chemotherapy. Sometimes this assessment is spread out a bit after you have had more chemotherapy having unusually severe side effects.
“Stable or improved disease” is the definition of success that you and your oncologist should use to assess how well the chemotherapy is working.
Lymph nodes - Tissues in the lymphatic system that filter lymph fluid and help the immune system fight disease.
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My doctor just told me that my cancer is in remission. Does that mean that I’m cured?
Remission is the word that oncologists use to describe how well the anti-cancer treatment is working. It is not the same as cure. Remissions are complete or partial. Complete remission means that there is no longer any sign of cancer on your examination, blood work, or scans. Partial remission means that there is less cancer in your body than there was before treatment, but that there is still some sign of cancer on your examination, blood work, or scans.
Sometimes partial remissions become complete remissions after you get more treatment. The more cancer the treatment kills the better, and complete remissions usually last longer than partial remissions. Unfortunately, when it comes to metastatic breast cancer, even complete remissions are not forever. Though not curable, metastatic breast cancer is usually quite responsive to initial therapy, and there is a good chance that you will enjoy a remission for some time before the cancer grows back.
What are my chances of remission, and how long will it last?
That is not an easy question to answer. Some women with metastatic breast cancer live with their disease in remission for years, while others never have a remission and die within months. The likelihood that your cancer will respond to treatment depends on many complex factors. Your overall health and well-being and the amount of metastatic disease are important, but the most important predictor is how well you respond to the first couple of cycles of therapy. Usually, the faster and more complete your initial response, the fuller and longer it will last. Every time your breast cancer comes back, the chance of it responding to a new treatment regimen decreases and the duration of the remission gets a bit shorter. With time, your breast cancer will no longer respond to treatment and the focus of your care will change to managing the symptoms, often with the help of palliative care or hospice nurses. Although the proper time for this transition is a very personal decision, most oncologists feel that the chances of responding to additional chemotherapy are virtually nonexistent if you have not responded to your last three chemotherapy regimens, or if you are spending most of your day in bed or a chair.
Breast cancer that has metastasized to the bone or soft tissues generally grows more slowly, and responds to treatment more completely and longer, than breast cancer that involves the liver, lung, or brain. Breast cancer that recurs after many years generally grows more slowly and responds to treatment better than breast cancer that recurs during, or shortly after, the initial diagnosis and treatment.
The likelihood that your cancer will respond to treatment depends on many complex factors.
I feel pretty good during my chemotherapy treatments, and I worry that the treatment isn’t strong enough. Is it more likely to work if I get more severe side effects?
This is a common myth. There is really no link between how well the chemotherapy works and the severity of the side effects. Different people tolerate chemotherapy in different ways, and some chemotherapy drugs cause more side effects than others do. If you are not having severe side effects from your treatment, relax and don’t worry. There are now excellent medicines that prevent many of the side effects of chemotherapy. You should take these as prescribed and without fear.
There is really no link between how well the chemotherapy works, and the severity of the side effects.
How often will I see my oncologist during my chemotherapy treatments?
You will see your oncologist regularly throughout your treatment. At these visits, your doctor will see how you are tolerating the treatment and if you are having side effects. He will order medication to relieve any side effects, and, if these are severe, he may adjust your treatment schedule or dose. Another reason for these visits is so that your oncologist can see if your cancer is responding to the treatment.
Your oncologist will probably want to see you at the beginning of each cycle of chemotherapy. Most oncologists try to do this the same day that you get the chemotherapy, but sometimes it is more convenient to do this a day or two before. If you have any problems in the middle of your chemotherapy cycle, you should call your doctor to see if she wants to see you sooner. If your oncologist works with a nurse practitioner or physician’s assistant, she may see you at some of these visits. The primary reason for these scheduled visits is to be certain that it is safe to begin the next cycle of chemotherapy.
You will have blood drawn to be sure that your blood counts have returned to normal. Your doctor will examine you and ask questions about any side effects of chemotherapy that you had during the last cycle of chemotherapy. You can help your doctor by keeping a diary of any problems, concerns, or questions that you had during the last cycle of chemotherapy. When it is time to see how well your cancer is responding to the chemotherapy, your oncologist will have you get the necessary scans and blood work a few days before your visit. He will review these with you at your visit and discuss future chemotherapy plans with you.
Since the chemotherapy affects my immune system, is it still okay for me to work while taking it? Are there any precautions I should use in the work place or in other social settings?
The purpose of chemotherapy is to allow you to live your life in as normal a manner as possible, for as long as possible. The chemotherapy will certainly affect you, but you should strive to go about your regular business as much as you can. Though the chemotherapy will affect your immune system, this is really only a problem when your white blood cell count is low.
White blood cells (WBC), more specifically, the group of white blood cells called neutrophils fight infection, and, when they are low, you are at increased risk for infection. Your white blood cells drop to their lowest point (nadir) in the middle of your cycle of chemotherapy, stay there for a few days, and then gradually increase back to normal. Your greatest risk of infection is, therefore, in the middle of your chemotherapy cycle.
It is prudent to minimize your exposure to sources of infections during the entire time that you are on chemotherapy, but this is most important during the nadir period. You do not need to be a hermit during this period, but you should not go out of your way to be around people with colds and fevers. This is easy to do in your own home where you can ask visitors to stay away if they are sick.
This is harder to do at work or in large social settings, especially if you do not want to share your diagnosis with co-workers and friends. You need to be in control of your environment, especially when your WBC count is low. If this is not possible, it is best to avoid these situations all together or, if you must, limit the time of your exposure and wear a mask. It should go without saying that you should not share things like towels or drinking glasses, and always use common sense hygiene measures.
Actually, most infections that people get during chemotherapy come from the germs that normally inhabit your intestinal tract or skin. Your immune system usually keeps these germs in their own place, but when your WBC count is low, they can sneak through these natural defenses and cause an infection. Over the years, studies have shown that antibiotics, nutritional supplements, or a change in your diet will not prevent this from happening. Fortunately, the majority of patients who get chemotherapy do not get infected, and those that do usually respond to antibiotics quite nicely. However, immediate treatment is critical, and it is very important for you to call your doctor right away if you have a fever or any signs or symptoms of infection-even if these occur at 2:00 in the morning!
The purpose of chemotherapy is to allow you to live your life in as normal a manner as possible, for as long as possible.
Actually, most infections that people get during chemotherapy come from the germs that normally inhabit your intestinal tract or skin
Nadir - The low point of blood counts that occurs as a result of chemotherapy.
(19) Metastatic Breast Cancer
My doctor checks my blood count just before I get my next dose of chemotherapy. Why does he also need to check it 1-2 weeks later?
Your blood counts reach their nadir about 1-2 weeks after you get your chemotherapy. After a few days, they start to rise, and usually return to normal in time for you to start your next cycle of chemotherapy. Your doctor checks your blood counts on the day that you get chemotherapy (or the day before) so that he will know if it safe for you to start your next cycle of chemotherapy.
If your white blood cells or platelets are too low, you will probably need to wait until they return to a safe level before you get your next treatment. Your oncologist may also want to know how low your counts get at their nadir. This helps her decide if she needs to modify the dose of your chemotherapy or the interval between your treatments. If your WBC nadir is unusually low, or if you have neutropenic fever or infection, your oncologist may decide to give you a cytokine (Neulasta or Neupogen) the day after your next chemotherapy infusion, to try to prevent this from happening again. He also uses these mid-cycle nadir blood counts to advise you on the need for any special precautions or treatments to protect yourself from infection (due to low WBC counts) or bleeding (due to low platelet counts).
Platelets - Components of blood that assist in clotting and wound healing.
Neutropenic fever - A fever due to a low white blood cell count, usually caused by a side effect of chemotherapy.
Is there anything that I can do to bring my counts up?
Not really. Your bone marrow makes your blood cells, and it is particularly sensitive to chemotherapy. Chemotherapy causes some degree of bone marrow suppression in almost everybody. Some chemotherapy drugs are harder on the bone marrow than others, but with time, your blood counts will rise. If your blood counts continue to be low, your doctor may need to decrease the dose of chemotherapy that you are getting. A lower dose of chemotherapy will probably kill fewer cells and allow you to get chemotherapy on schedule. Another approach is for your doctor to give you a cytokine (for example G-CSF, Neupogen, or Neulasta) injection the day after you get your chemotherapy.
An oncology nurse usually gives you this injection subcutaneously, or under the skin. If you are curious about the physiology of how this works, cytokines or colony-stimulating factors (CSFs) are growth factors that stimulate your bone marrow to make white blood cells. CSFs increase the recovery rate from bone marrow side effects of chemotherapy and radiation. Bone marrow side effects lower blood counts. Sometimes oncologists give CSFs in the middle of a chemotherapy cycle to limit the period of neutropenia, especially if you have a severe infection. You may experience some bone discomfort a day or two after you get a CSF. This is due to the rapid growth of blood cells in the confined space of the bone marrow. This pain is usually mild and controlled with acetaminophen (Tylenol) or ibuprofen, but sometimes you have to take stronger medicine for a few days.
When I have a problem, should I call my primary care doctor or my oncologist?
That depends on what the problem is. Your cancer or treatment may affect your other medical problems, and it is critical that all of your doctors communicate with each other. For example, the corticosteroids (prednisone or Decadron) that oncologists use as chemotherapy premedication, or to help control nausea and vomiting, may make gastric acid problems worse or increase your blood sugar making your diabetes worse. If you have high blood pressure, your doctor may need to adjust your antihypertensive medicines. Most oncologists prefer that your
A primary care doctor continue to manage your non– A cancer-related problems, but since your primary care doctor may not always be aware of some of the problems associated with certain cancers or cancer treatments, it is important that you tell your oncologist about all of your medical problems. For example, the low-grade fever and sore throat that your primary doctor usually tells you to treat with acetaminophen and salt water gargles may require hospitalization and intravenous antibiotics in the setting of a chemotherapy-induced low white blood count. A good rule of thumb is, when in doubt, call your oncologist’s office, and let them decide who should take care of the problem.
Primary care doctor - The physician (internist or family doctor) who takes care of your general healthcare needs.
Why do I need intrathecal chemotherapy?
Chemotherapy reaches cancer metastases through the bloodstream, but the blood-brain barrier interferes with its ability to reach brain metastases. This barrier prevents germs and other disease-causing agents from reaching the brain. The same barrier that prevents germs from reaching the brain and protects you from infections also prevents chemotherapy from reaching your brain and protects brain metastases from chemotherapy. It is very difficult to break down this barrier. The only effective way to get chemotherapy into the brain or the tissues surrounding it (meninges) is to bypass it. Doctors do this by putting the chemotherapy directly into the fluid that surrounds the brain. From there, it can penetrate the cancer cells that seed the lining of the brain (carcinomatous meningitis). The fluid that is in contact with the meninges of the brain also circulates down the spinal canal. Therefore, it is possible for your doctor to treat these metastases by doing a spinal tap and injecting chemotherapy into the spinal canal. If you need repeated injections of chemotherapy, it is usually easier to do this through an Ommaya reservoir placed directly into one of the ventricles (lakes of spinal fluid) in your brain. This may sound dangerous, but it really is not. This relatively minor surgical procedure is quite similar to having a port placed in the large veins in your chest.
Blood-brain barrier - A special layer that protects the brain from infection. This layer is made up of a network of blood vessels with thick walls.
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Is it true that bone marrow transplant is better than standard chemotherapy?
High-dose chemotherapy with bone marrow (or stem cell) transplant is a way of giving high doses of chemotherapy and replacing blood-forming bone marrow cells destroyed by the cancer treatment. It is actually more like a fancy blood transfusion than an organ transplant. Stem cells are removed from the blood or bone marrow of the patient or a donor and are frozen and stored. After the chemotherapy is completed, these stem cells are thawed and given back to the patient through an intravenous infusion. These reinfused stem cells home to the bone marrow where they grow into and restore the body’s blood cells.
Though high-dose chemotherapy followed by stem cell transplant is useful in a number of cancers, studies have clearly shown that it does not work any better than standard chemotherapy in the treatment of breast cancer. Indeed, these studies showed that more breast cancer patients died of treatment side effects with this treatment than those who got standard treatment.
Since the goal of chemotherapy is to allow you to live your life, it is imperative that you do so, sometimes despite the chemotherapy itself.
Is it safe to travel while I am getting chemotherapy?
Although sticking to the chemotherapy schedule is important, the schedule is not nearly as inflexible as many people think that is. You will probably be getting chemotherapy for the rest of your life. Since the goal of chemotherapy is to allow you to live your life, it is imperative that you do so, sometimes despite the chemotherapy itself. Holidays, vacations, and family lifecycle events are part of everyone’s life. Just because you are getting chemotherapy does not mean that you need to forgo these pleasures. Tell your oncologist when they will occur, and do not be surprised when she accommodates your chemotherapy schedule around those events. Unless it becomes a regular practice, a day here or there, or an occasional extra week between cycles, will have little impact on how well the chemotherapy works; especially once you have a few treatment cycles under your belt. During your regular cycle of therapy, there are better times to travel than others. The best time to travel is once you are through the period of nadir cytopenias, just before you are due to get your next treatment. Make sure that your oncologist knows of your travel plans, and be sure to carry with you a summary of your chemotherapy treatment and latest blood counts. If you do not have access to a doctor through the friends or relatives whom you plan to visit, ask your oncologist to give you the name of a local oncologist in case you run into trouble. Of course, make sure that you take your oncologist’s telephone and fax number with you.
How does the doctor determine if I should get hormonal therapy instead of chemotherapy?
Hormonal therapy is only an option if your cancer cells have hormone receptors present. When your breast cancer was first biopsied, the pathologists tested your cancer cells to see if estrogen receptors (ER) or progesterone receptors (PR) were present. Unless this test found at least one of these hormone receptors, your cancer will not respond to hormone therapy. Breast cancers may keep the same hormonal receptor profile forever. However, from time to time, hormone receptor–positive cancers become negative.
It is unusual for a hormone receptor–negative cancer to change to hormone receptor–positive. If your doctor suspects that the hormone receptor status of your cancer may have changed, she may want to biopsy one of the metastatic spots and send it to a laboratory for estrogen and progesterone receptor tests.
If your cancer is not estrogen receptor–positive or progesterone receptor–positive or both, chemotherapy is your only option. If it is hormone receptor–positive, your doctor can use either chemotherapy or hormonal therapy to treat your cancer.
Hormone therapy is usually the first treatment used in postmenopausal women, unless their tumor is hormone receptor negative. Though it may have side effects, they are usually tolerated much better than the side effects of chemotherapy. Hormone therapy is especially useful in patients whose metastatic disease involves only bone or soft tissue. Though it is also useful in treating metastases to the vital organs (liver, lung, etc.), chemotherapy often works faster in these situations. If your cancer has recurred while you are taking adjuvant hormonal therapy, your doctor may prefer to switch to chemotherapy as the initial treatment for your metastatic cancer, especially if your cancer involves sites other than the bone or soft tissues. Another option would be to switch to a different type of hormonal therapy than you are currently using.
It frustrates me that I’m only receiving hormonal therapy right now for treatment of my recently discovered metastatic disease. I want it cut out, killed with chemo, and zapped away with radiation. That makes sense to me. The doctors say that less aggressive treatment may get it into control-that is the mission now. I still think that the mission is to be cured. I need to start thinking of this disease as a chronic disease and that is hard to do.
Are there different types of hormonal therapies? How does my doctor decide which to use?
Different types of hormonal therapies are used to treat cancer in postmenopausal women than those used in premenopausal women. Aromatase inhibitors (AIs) are usually the anti-estrogen of choice in postmenopausal women. Though tamoxifen is quite effective in postmenopausal women, the AIs work better and have fewer side effects. Because they have no effect on estrogens produced by the ovaries, AIs do not work in premenopausal women. Sometimes doctors combine hormone therapy (for example, buserelin and tamoxifen). Women whose tumors are hormone receptor positive and have received anti-estrogens within the past year may still respond to second-line hormonal therapy. Examples of second-line hormonal therapy in postmenopausal women include AIs like anastrozole, letrozole, or exemestane. Fulvestrant is another useful antiestrogen. Premenopausal women with hormone receptor–positive breast cancers should undergo oophorectomy, either surgically, induced with radiation therapy, or with medicine. Tamoxifen is also an option for premenopausal women, whose cancer is hormone receptor–positive and was not treated with it in the past. Different types of hormonal
Therapies are used to treat cancer in postmenopausal women than those used in premenopausal women.