By Marisa Weiss
WebMD Live Events Transcript
Chemotherapy can conjure mixed emotions of hope and fear for those with cancer. Understanding how anticancer drugs work, knowing what to expect and what questions to ask your doctor can help you feel more at ease about your treatment regimen. Marisa Weiss, MD, co-author of "Living Beyond Breast Cancer," joined us to answer your chemo questions.
The opinions expressed in this transcript are those of the health professional and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Moderator: Hello, Dr. Weiss. Welcome back to WebMD.
Weiss: Well thank you for having me.
Member: Found out yesterday: right breast, cancer. One large mass and one small satellite. Surgeon said, "I also feel the lymph gland" (is that the way you say it?). Said, "mastectomy" because too large for lumpectomy. Said I could also use chemo for two to three months to try to shrink mass and then do lumpectomy. I'm 43, what is the success rate of that?
Weiss: You seem to be dealing with two separate issues. First is the question of whether it is possible to keep your breast rather than have to sacrifice your breast. Your doctor is concerned that there are two separate cancers in the same breast. Whenever there is more than one cancer present, mastectomy is usually recommended. Lumpectomy and radiation therapy are usually only offered to women with only one site of cancer that can be removed with clear margins.
The second issue you mentioned is the size of the cancer. If you are dealing with one cancer that is relatively large, like 4-5 cm or greater, then your situation may not be ideal for breast preservation therapy. Under these circumstances, if a woman wants to keep her breast if at all possible, there may be a role for up front chemotherapy (otherwise known as "neoadjuvant" chemotherapy) with a purpose of shrinking the tumor down to a small enough size (under 4 cm) so that you could be treated with lumpectomy and radiation as an alternative to mastectomy.
For some women who have an irregularly shaped cancer in one part of the breast that may be one cancer process or possibly two lumps huddled together, you may want to have additional studies to distinguish between these two presentations. An MRI scan and sometimes an ultrasound or mammogram can help figure this out. Good luck with your situation. Read further at www.breastcancer.org regarding all these tough decisions.
Member: Are there any standards regarding selection of the particular type of chemo used for small primary breast cancers?
Weiss: Yes. Every woman's situation is unique and different from anyone else's. We try to use current guidelines to pick the best treatments possible. The selection of chemotherapy can depend on the specific tumor characteristics found in your pathology report. For example, if you have a cancer that is HER2 positive, your doctor may select an adriamycin-based chemotherapy rather than CMF chemo. For women whose cancers have estrogen or progesterone receptors present, anti-estrogen therapy usually has an important role. There are other considerations like this that your doctor may use in guiding you. Also if you are perimenopausal, and want to preserve fertility, if possible, most doctors would avoid using CMF.
Member: Why would doctors avoid using CMF?
Weiss: Both chemotherapy treatments are generally very effective. In general they are almost equally effective, depending on subtle differences in an individual's situation. CMF is usually given over a six-month period. It is associated with minimal hair loss and that's why many women prefer this approach. It is also associated with a slightly higher risk of infertility in premenopausal women. AC chemotherapy is given over a three-month period and is associated with complete hair loss. In the US, most doctors prefer AC for young women. AC is also better for cancers that are HER2 positive.
Member: I had a lumpectomy and only one lymph node had cancer. Will I still need chemo or is there an alternative? I am also past menopause. If I receive chemo, am I likely to receive a dose less than someone who might have had cancer in several nodes?
Weiss: These are excellent and interesting questions. The role for chemotherapy depends on a number of different features about the cancer including:
- Tumor size
- Tumor growth rate
- Hormone receptor status
- Presence of lymphatic or vascular invasion
- HER2 status
- Lymph node involvement
It also matters how many lymph nodes are involved. For example, if there are more than four positive nodes -- in particular, if there are more than 10 positive nodes -- then more aggressive chemo may be offered.
In general, for each chemotherapy regimen, the doses prescribed are standard. For women who are beyond the menopause and who have a need for treatment to the whole body, in case cancer has spread, anti-estrogen therapy may be sufficient after local treatment is completed, only if hormone receptors are present. Given how complicated these decisions are it is critical you talk to your own doctor for the best guidance in your situation.
Breastcancer.org provides free booklets on and offline called Understanding Your Breast Cancer Pathology Report. This can help you understand a lot of the complex information you need to sort through in order to make the best decisions for your life.
Member: I am trying to understand the differences between my two chemo treatments. I have had a mastectomy with five positive lymph nodes. I had four treatments with adriamycin and Cytoxan. I have just started Taxotere treatment. Could you help me understand the differences?
Weiss: In the U.S., for women with lymph nodes involved, and particularly for women who have lymph node involvement and hormone-receptor negative tumors, treatment with AC times four followed by Taxol or Taxotere is frequently recommended. It takes six months to get all eight of these treatment doses. In Europe, doctors tend to use other types of chemo, like CEF (the E stands for epirubicin). This is another effective regimen. It also takes six months to get. Most doctors would recommend some form of chemotherapy for at least six months in your situation.
You may wonder why so many types of chemotherapy are necessary together or in sequence. This is because cancers are made up of a combination of many different types of cells. It may take a number of different types of treatments together to get rid of the variety of cancer cells that may be present. Keep in mind that the surgery you already had may have completely eradicated all disease. The purpose of the chemotherapy is to get rid of any possible residual cancer cells, in case any were present.
Member: I am a stage 4, second time BC patient. I just did three months of weekly high-dose chemo and one and a half years of regular chemo. Besides my doctor and the drug company, where can I get info on the long-term side effects of doing so much chemo?
Weiss: I understand your frustration and your need to know and be in control of what is happening with your body. For women with stage 4 breast cancer, where the cancer has spread to other parts of the body, some form of ongoing continuous treatment is necessary. This may involve anti-estrogen therapy, like tamoxifen, Arimidex, Fenara, Aromasin, Faslodex, for women who have hormone receptor positive cancer. These types of treatments may work over an extended period of time. Eventually, you may need chemotherapy. For women with HER2-positive cancers that are metastatic breast cancer, then Herceptin alone or in combination with chemotherapy may be best.
If the cancer is hormone-receptor negative, you may need chemotherapy sooner than later. Once you start with chemotherapy, you may need to continue getting it over an extended period of time. There are many different types of drugs that you may end up taking. Usually you stay on one type of drug as long as it continues to help you. If the disease starts to progress and grow under one kind of chemo, your doctor will usually switch you over to another kind.
In terms of long-term side effects from long-term chemo, it kind of depends on what drugs you are exposed to and for how long. At the very least, ongoing treatment tends to lower your immune system, cause fatigue, as well as inconvenience and expense. But the fact is that metastatic disease itself causes side effects like pain, pressure, fatigue, as well as other possible symptoms. Although it may seem surprising, for women with metastatic disease that is symptomatic in these ways, chemo can really help improve your quality of life. For women with stage 4 disease, chemo may be given in a different way than women with earlier stages of disease. For example, Taxotere may be given in lower doses once a week. Herceptin for women with HER2-positive disease can be given weekly alone for years with relatively minimal side effects. Generally, you continue to take something as long as it is working and as long as the side effects are acceptable.
Also, there are many medications available to help ease any side effects you might have. This includes an anti-nausea medicine, pain medication, as well drugs like Procrit to boost your blood count and Neupogen to boost your immune-cell count. You need to let your doctor know if you are suffering in any way from these symptoms.
Member: How many years after a person gets chemo do they feel the side effects?
Weiss: Most side effects of chemotherapy are relatively short lived, thank goodness. Some symptoms like aches and discomfort can last months longer or even a year. If you are close to age 40 and older and you receive chemotherapy, it is likely that you will be thrown into an early menopause. The fatigue you may get after treatment can last a very long time. But we need to be careful about attributing all side effects to chemotherapy. When so many things happen at the same time, sometimes it's hard to know where to point the finger. For example, upon diagnosis after surgery, radiation, and chemotherapy, you may find that you are depressed and in a struggle with a lot of weight gain. You may have had to stop taking hormone replacement therapy upon diagnosis.
Each one of these changes in your life can contribute to your overall sense of well-being or illness. Talk to your doctor about the specific symptoms you are experiencing to help figure out how to relieve them and improve your quality of life.
Weiss: I have been impressed by the ability of marijuana, medically speaking of course, to relieve nausea, increase appetite and sense of well-being, and increase energy. Not all people tolerate this drug well. In addition to these benefits, it may make you feel somewhat high. It is not safe to drive or be responsible for someone other than yourself when using this and other similar medications.
Member: What about maintaining good nutrition during chemo treatment? Should we be avoiding certain foods that may interfere with good health during this period?
Weiss: Good nutrition is very important during chemotherapy. That also includes good "hydration" -- meaning that you also drink well in addition. The taste of food may be altered, however. You may be repulsed by red meat, for example. Food like tomato sauce may take on a metallic taste. Some women crave junk food to ease or avoid nausea. Try to do the best you can at eating plenty of fruits, vegetable, whole grains, and low-fat sources of protein.
I am not aware of any "dangerous" food to avoid. Some people do say avoid taking anti-oxidants during adriamycin chemotherapy and during radiation. This is because these vitamins may interfere with the way these treatments work. Anti-oxidant vitamins include, C, A, E, plus some other supplements that you may hear about. Many doctors are concerned that the estrogen-like molecules in soy may stimulate the estrogen receptors present in estrogen-receptor positive cancers. For this reason, some doctors might tell you to avoid all soy products and foods. The fact is that this still remains very controversial. These estrogen-like substances are very, very weak estrogens. It's unlikely that the amount of these substances present in soy foods like tofu or soy milk or soy nuts would put you in any danger. Plus no matter how you cook it, most people don't find these foods so irresistible that they would want to eat tons of it. On the other hand, I do think one should be very careful about taking concentrated soy powders and liquids and pills because they have concentrated pharmaceutical-grade anti-estrogens present in them. We just don't know enough about their safety yet to feel comfortable with them. Soy proteins found in food are probably a healthier source of protein than red meat or chicken.
Member: Is it true that the current trend regarding adjuvant therapy is leaning toward chemotherapy for anyone diagnosed with invasive breast cancer, regardless of size?
Weiss: In general, adjuvant chemotherapy (adjuvant means after surgery for early-stage disease) is offered to women with cancers over 1 cm. For women whose cancers are relatively small but still over 1 cm, doctors will take into consideration other factors mentioned earlier to help estimate the risk of recurrence as well as the benefits of chemotherapy. For women whose cancers are less than 1 cm, in general, chemo is not offered. Exceptions may be made, for example, if the cancer is high-grade, with lymphatic or vascular invasion, or HER2 positive.
There are many women who may find themselves in the "gray zone" where their prognosis is already quite good and the benefit of chemotherapy may be relatively small. You need to think about your style of making decisions. How far do you want to push to do everything possible to reduce the risk of recurrence? For young women with young children, they usually push very hard. For woman who may not have as many responsibilities and who may have lived a full life, they may not choose to be quite as aggressive.
The decision to have or not to have chemo and the selection of the best treatments are difficult to sort through and decide upon. Gather the information that you need and take the time required to understand and process the options presented to you. You need to feel comfortable with the treatment decisions that you make. Tune into breastcancer.org to learn about many of these treatment options and come back next week and the next few Thursdays at WebMD for other chances to talk about information on breast cancer.
Moderator: Unfortunately we are out of time. Our thanks to Marisa Weiss, MD, for joining us tonight. For more information on chemotherapy and other breast cancer issues, read Living Beyond Breast Cancer by Marisa Weiss, MD. Also be sure to explore all of the breast cancer info here at WebMD, including our message boards and live chats.
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