Chemotherapy

The use of chemotherapy for the treatment of cancer began in the 1940’s with the use of nitrogen mustard.  In the attempt to discover what is effective in chemotherapy, many new drugs have been developed and tried since then. Chemotherapy is used most often to describe drugs that kill cancer cells directly, and these drugs are sometimes referred to as “anti-cancer” drugs.
Today’s chemotherapy uses more than 100 drugs to treat cancer.  There are even more chemo drugs still under development and investigation.  Various chemotherapy drugs are available to treat breast cancer.  Breast cancer chemotherapy is made of powerful drugs that target and destroy fast-growing breast cancer cells.  The drugs may be used individually or in a combination to increase the effectiveness of the treatment.  Breast cancer chemotherapy is frequently used along with other treatments for breast cancer, such as surgery.  Chemotherapy may also be used as the primary treatment when surgery isn’t an option.  Chemotherapy can help you live longer and reduce your chances of recurrence. It also carries the risk of side effects.  Some of the side effects are temporary and mild but others more serious, and sometimes permanent.  Your doctor can help you decide whether chemotherapy for breast cancer is a good choice for you.  Chemotherapy drugs are given intravenously or orally for treating breast cancer.  The drugs enter the blood stream and travel to all parts of the body, thus reaching cancer cells that may have spread beyond the breast.
Chemotherapy is given in cycles of treatment; and the entire chemotherapy treatment generally lasts several months to one year, depending on the type of drugs given.  A period of recovery is granted after the chemotherapy is finished.
Your doctor considers a number of factors to determine whether and what kind of chemotherapy would be of benefit to you.  The higher your risk of recurrence or metastasis, the more likely chemotherapy will be of benefit. In some cases, characteristics of the breast cancer itself may suggest other more beneficial treatments.  Discuss your own treatment goals and preferences with your doctor.
Factors commonly considered include:
Tumor size and grade. The more advanced the tumor, the more likely chemotherapy may be useful in destroying any stray cancer cells.
Lymph node status. If breast cancer cells were found in your lymph nodes during or before surgery, this is an indication of a higher risk of metastasis and thus an indication for chemotherapy.
Age. Some studies suggest that breast cancer which occurs at a young age is more aggressive than is breast cancer that develops later in life. Thus, doctors may opt for adjuvant chemotherapy when treating younger women to decrease the chances of the cancer spreading to other areas of the body.
Previous treatments. Whether you’ve had chemotherapy before may affect your current treatment regimen.
Chronic health conditions. Certain health problems, such as heart disease or diabetes, may affect your choice of chemotherapy drugs.
Hormonal status. If your breast cancer is sensitive to the hormones estrogen (ER) and progesterone (PR), hormone therapy — with drugs such as tamoxifen, fulvestrant (Faslodex) or aromatase inhibitors (Arimidex, Femara, Aromasin) — may be a better option for post-surgical adjuvant therapy or they may be considered in addition to chemotherapy.
HER2 status. If your breast cancer produces (expresses) too much of a growth-promoting protein known as human growth factor receptor 2 (HER2), your doctor may recommend drugs that specifically target this protein — trastuzumab (Herceptin), lapatinib (Tykerb) — in addition to chemotherapy.

Accelerated Partial Radiation

Have you heard of accelerated partial radiation before?
Women who are diagnosed with early-stage breast cancer often choose to have the cancer removed by lumpectomy, and they usually have radiation therapy after surgery as well.   Radiation therapy after lumpectomy lowers the risk of the cancer recurring and it makes lumpectomy as effective as mastectomy.  Radiation can be delivered to the entire breast, whole-breast radiation, or to just the area of the breast where the cancer was located, partial-breast radiation.  Traditional whole-breast radiation typically lasts 5 days a week for 4 to 6 weeks; and the unintentional exposure of nearby healthy tissue (lungs or heart, for example) to is a factor to consider as well.
One of the newer ways to deliver radiation is accelerated partial-breast radiation.   This is a new technique that delivers a more focused and intense  therapy over a shorter period of time.
3-D conformal external beam radiation (3DCRT) is one type of accelerated partial-breast radiation.  3DCRT starts with a planning session.   A special MRI or CAT scan of the breast is done and is used to map out small treatment fields for the area at risk.  The type and distribution of radiation is designed to maximize the dose to the area that needs to be treated and avoid or minimize radiation to tissue near the area.  The radiation is delivered with a linear accelerator, the same machine used in traditional whole-breast radiation, twice a day for 1 week.
A study has found that women diagnosed with early-stage breast cancer and had 3DCRT after lumpectomy had worse cosmetic results than women who got traditional whole-breast radiation after lumpectomy.  The study was published online on July 8, 2013 by the Journal of Clinical Oncology.
In the RAPID trial, researchers randomly assigned 2,135 women diagnosed with either early-stage breast cancer or DCIS to get either 3DCRT (1,070 women) or whole-breast radiation (1,065 women) after lumpectomy.  Before they received any radiation therapy, all the women were assessed by a trained nurse using a cosmetic rating system for breast cancer.  After radiation therapy, the women were again assessed by a trained nurse at 2 weeks, 3 months, 6 months, 12 months, and then once a year.
The rating system compared the treated and untreated breast for:

• size and shape
• location of the nipple and areola
• how the surgical scar looked
• whether or not there was an enlargement of small blood vessels on the skin
• overall appearance of the breasts

The researchers then compared cosmetic results and side effects between the two types of radiation.
The researchers found that women who had 3DCRT had worse cosmetic results than women who had whole-breast radiation:

• Before radiation, 18.9% of women who would get 3DCRT had fair or poor cosmetic results compared to 17% of women who would get whole-breast radiation.
• Three years after radiation, 29% of women who had 3DCRT had fair or poor cosmetic results compared to 16.5% of women who got whole-breast radiation.
• Five years after radiation, 32.8% of women who had 3DCRT had fair or poor cosmetic results compared to 13.4% of women who got whole-breast radiation.

Looking at side effects, the researchers found that women who had 3DCRT were more likely to have telangiectasia and breast induration (hardening or thickening of the skin) than women who had whole-breast radiation.  About a quarter of the women in both groups had mild to moderate pain after radiation.  Very few women in either group had severe pain.
While other ongoing studies have suggested that accelerated partial-breast irradiation is safe, none of these other studies have reported on cosmetic results.  Since the cosmetic results and side effects were worse with 3DCRT than whole-breast radiation, the researchers recommended that 3DCRT not be routinely used unless it’s part of a clinical trial.  More research with long-term follow-up is needed so doctors know for sure that accelerated partial-breast irradiation is a good alternative to whole-breast radiation.
If you’ve been diagnosed with early-stage breast cancer and lumpectomy followed by radiation therapy will be part of your treatment, ask your doctor about the radiation therapy options that make the most sense for your unique situation, including:

• the characteristics of the cancer (size, location, lymph node involvement)
• your personal preferences
• the experience level and results of the doctors who will administer your radiation therapy