Breast Cancer Treatment - Chemotherapy and Hormonal Therapy, Part 3
Although in most cases chemotherapy is given as the initial treatment, in elderly women or women with significant medical problems hormonal agents, such as tamoxifen or an aromatase inhibitor, may be given first. If these treatments are not successful in shrinking the tumor, then radiation may be used prior to surgery. In these locally advanced cancers, it is important that surgery is not done first because the risk of recurrence and treatment failure is extremely high if surgery is done first. Here, the multidisciplinary approach to treatment and planning is especially important. Because all three modalities will be used (surgery, radiation, and systemic treatments), all three specialties should be consulted prior to starting any treatment.
Metastatic breast cancers have spread outside of the breast, chest wall, and lymph nodes to involve distant sites, most commonly bone, liver, or lung. At this stage, the cancer is not curable but is still treatable, much like a chronic illness. For a few women, the cancer is found to have spread at the time that the breast tumor is found, but for most women this news comes months to years later. Often, women feel more devastated with this news than they did when they were first diagnosed.
When cancer has metastasized, many patients ask for the most aggressive treatment possible. However, the goals of treatment are different and approach to decision making is very individualized. Each treatment needs to be considered in its totality, including how likely it is to work, but also what side effects can be expected and how the treatment affects day-to-day quality of life. Each patient should think about what is most important to her.
Patients must weigh the pros and cons of, for example, oral medications they can take at home versus intravenous medications that are given in the clinic. Some patients may want to avoid medications that cause nausea or lead to hair loss. By thinking about priorities, you and your family, together with your medical oncologist, can choose an effective treatment that maximizes your quality of life.
Hormone agents are highly effective in women with metastatic breast cancer that is estrogen or progesterone receptor-positive. These hormone agents are generally considered first, because they work well while having few side effects. In addition to tamoxifen and aromatase inhibitors (see above), another strategy involves using a drug that destroys the estrogen receptor. This drug is called fulvestrant (Faslodex) and is administered as a monthly injection.
Chemotherapy for metastatic breast cancer is considered for women whose tumors are estrogen receptor-negative; women whose tumors are estrogen receptor-positive but who have been resistant to hormonal therapy; or women whose tumors are estrogen receptor-positive and whose disease is rapidly progressing in critical organs such as the liver. Chemotherapy can be given as single agents, tried one at a time and continued as long as they are working and side effects are tolerable. Alternatively, combinations of drugs may be given, often similar to the combinations used for early-stage disease. Active drugs include: Taxol, Taxotere, capecetabine (Xeloda), vinorelbine (Navelbine), gem-citabine (Gemzar), or liposome forms of doxorubicin, such as Doxil.
In women who have metastatic disease, it is crucial to know whether or not the tumor over-expresses the Her-2 neu oncogene. In those 23 to 30 percent for which this is the case, it is important to add the monoclonal antibody Herceptin to the treatment regimen. Herceptin is most effective when used in combination with a chemotherapeutic drug or combination, although it can be used alone. Active combinations include Herceptin and either Taxol or Taxotere; Herceptin and Navelbine; or Herceptin, Carboplatinum, and Taxol.
Once again, ask about clinical trials. This may be an opportunity to get a new biologic agent, a targeted treatment, or a new drug that is not yet commercially available. You can get more information about clinical trials by logging on to the website for the National Cancer Institute: cancer.gov/search/clinical_trials.