A medical oncologist is a specialist who prescribes medications such as chemotherapy or hormones to weaken and destroy cancer cells in the body.
Chemotherapy may begin prior to surgery, or four to six weeks after the final surgery. Typically, multiple chemotherapy agents are used in combination. The schedule of administration depends on the chemotherapy used; most often, in newly diagnosed patients, treatments are given every two to three weeks (each treatment being a cycle) for four to eight cycles. Cycling chemotherapy gives the body a chance to rest and recover between treatments. An entire course of chemotherapy may last from three to 12 months, depending on the specific medications.
The decision to use chemotherapy is personal to every patient, and a combination of several factors should be taken into consideration. However, there are some general guidelines to follow in the decision of whether or not to utilize chemotherapy.
In premenopausal women, chemotherapy is most often recommended for women with:
Tumors larger than 1 cm, whether or not lymph nodes are involved
Any size tumor, if lymph nodes are found to be positive for cancer cells
Although this is controversial, some premenopausal women with node-negative cancer, whose tumors are smaller than 1 cm, may choose or be advised to undergo chemotherapy if certain tests show the cancer to be more aggressive.
In postmenopausal women, the decision to choose chemotherapy is a bit more complicated because it may not be as effective.
One important consideration for postmenopausal women is estrogen/progesterone receptor status. Because hormone/endocrine therapy (tamoxifen, aromatase inhibitors) is generally of greater benefit than chemotherapy in postmenopausal women with tumors that are estrogen/progesterone receptor positive, they may be less likely to opt for chemotherapy.
That said, chemotherapy is most often recommended in postmenopausal women with:
Tumors larger than 1 cm that are estrogen and/or progesterone receptor negative, regardless of nodal status
Tumors that are estrogen and/or progesterone receptor positive, but nodes prove to be positive, or tumor is a larger size
Patients who have other medical illnesses may not be candidates for chemotherapy, as the risks may outweigh the benefits. Decisions about systemic therapy for breast cancer are an integral part of your breast cancer treatment and should be made in consultation with you oncologist.
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What is systemic therapy for breast cancer?
Systemic treatment for breast cancer may be taken in pill form or infused into a vein (intravenous), or a combination of the two may be used. Intravenous medications are administered in Emory's ambulatory infusion center. Each chemotherapy session typically lasts from two to six hours and may be given from 1-3 weeks apart. First, labs will be drawn to ensure adequate blood counts. Then you will meet with your provider team, and with approval from the team, your particular chemotherapy combination will be created.
Side Effects of Chemotherapy
Side effects are common during chemotherapy. Many are short-term, meaning that they develop during treatment and begin to subside shortly after treatment ends. There are several ways to address adverse effects, so it is important to let your oncology team know of any bothersome symptoms.
Fatigue: Anemia (a decrease in the oxygen-carrying red blood cell count) and chemotherapy may cause fatigue.
Infection: Chemotherapy causes your white blood count to fall, putting you at risk for serious infections. It is essential to let your oncology team know if you develop a fever over 100.5, especially after your first week of treatment. Treatment may include antibiotic therapy by mouth, or may require hospitalization to administer IV antibiotics.
Gastrointestinal irritation: Nausea, vomiting, diarrhea or constipation are common side effects of chemotherapy and can be prevented and/or treated. It's important that you make your oncology team aware of any symptoms.
Sore Mouth: Mouth pain is another possible side effect of chemotherapy, and is often referred to as stomatitis. Your nurse educator will provide you with information on appropriate oral care.
Hair Loss: Amount of hair loss depends on the type of chemotherapy. In most cases, hair grows back within three to six month after the completion of chemotherapy.
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In two out of three breast cancers, estrogen promotes the growth of tumors. These types of tumors are called estrogen receptor-positive (ER-positive) or progesterone receptor-positive (PR-positive). Women with ER-positive and/or PR-positive breast cancer are often treated with medications to lower estrogen levels or block the effect of estrogen.
This type of therapy is usually given after surgery, radiation, and/or chemotherapy to stop any remaining estrogen production. Hormone therapy does not help patients whose tumors are both ER- and PR-negative.
Side effects of hormone therapy include fatigue, hot flashes, mild nausea, vaginal dryness or discharge, and mood swings.
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Targeted Therapies: The development of targeted therapy represents an exciting new approach to cancer treatment. A small number of these drugs have already been FDA-approved, and a number are currently in clinical trials.These new drugs target processes specific to cancer cells. This means they are able to damage and kill cancer cells without harming healthy cells. Targeted therapies offer the hope of being highly effective with fewer side effects.
Blocking a single pathway in a cancer cell may be enough to slow it down, but it often does not inhibit the cancer enough to kill it. Therefore, many specific cancer drugs are currently being used together with traditional chemotherapy. The combination of a highly specific cancer drug that is able to attack a tumor's weaknesses, and standard chemotherapy to deliver a powerful attack on the tumor, may prove to be an excellent means of treating cancer.
An example of a targeted agent which is used in breast cancer is Herceptin. Herceptin is an antibody that targets a protein called HER2 which is present in about one-third of breast cancers. Herceptin is approved for the treatment of both early stage and advanced breast cancer and has imrpoved outcomes when given with chemotherapy for patients with HER2-positive disease. Herceptin can cause heart failure in very rare cases and your heart function will be monitored while you take it. Herceptin is only effective in patients with HER2-positive cancers (cancers that have very high levels of HER2).
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