Breast Cancer

Lesson 5: Adjuvant Therapy & Possible Side Effects

Chemotherapy

Chemotherapy is one of the adjuvant treatments for breast cancer. Not everyone who is diagnosed will undergo chemotherapy, nor will everyone receive the same type of chemo, nor the same duration or protocol. Hopefully, this section will give you a general overview of chemotherapy and help you to make an informed decision about your treatment. You, as the patient, need to be an active partner on your health care team. It's your life, your body - gather the facts, research the choices, discuss with whomever you wish and then make an informed decision. I'm going to list the most common drugs given as breast cancer chemotherapy, and a brief description of the action of each: These are the common chemotherapy drugs, not those associated with metastatic disease

ADRIAMYCIN (doxorubicin) SYMBOL: A WHAT IT DOES: Ruins DNA synthesis HOW ADMINISTERED: Intravenous POSSIBLE SIDE EFFECTS: Hair loss, nausea, may damage heart

CYTOXAN (cylcophosphamide) SYMBOL: C WHAT IT DOES: Interferes with cell growth HOW ADMINISTERED: Intravenous or oral POSSIBLE SIDE EFFECTS: Hair thinning, weakened immunity

ELLENCE (epirubicin) SYMBOL: E WHAT IT DOES: Ruins DNA synthesis HOW ADMINISTERED: Intravenous POSSIBLE SIDE EFFECTS: Hair loss, nausea,weakened immunity

5-FLUOROURACIL SYMBOL: F WHAT IT DOES: Stops DNA synthesis HOW ADMINISTERED: Intravenous POSSIBLE SIDE EFFECTS: Nausea, diarrhea,tingling hands/feet

METHOTREXATE SYMBOL: M WHAT IT DOES: Ruins DNA synthesis HOW ADMINISTERED: Intravenous POSSIBLE SIDE EFFECTS: Nausea, weakened immunity, gastrointestinal problems

TAXOL (paclitaxel) WHAT IT DOES: Inhibits cell division HOW ADMINISTERED: Intravenous POSSIBLE SIDE EFFECTS: Hair loss, fluid retention, numbness in extremities, weakened immunity

TAXOTERE (docetaxel) SYMBOL: T WHAT IT DOES: Inhibits cell division HOW ADMINISTERED: Intravenous POSSIBLE SIDE EFFECTS: Hair loss, fluid retention, numbness in extremities, weakened immunity

I know that the side effects listed can seem daunting, but take heart! Not everyone gets every side effect and some last a few minutes only, or occur only once during your series of treatments. There are many ways to counteract the side effects and we will discuss these in another article. For now, please remember that adjuvant therapy is changing on almost a daily basis - the combination of drugs used, the length of treatment, the reduction of side effects, which drug is used for your particular breast cancer...

This list is not meant as the final say-so, it is merely a list of the common drugs used in chemotherapy and the list of their most often cited side effects.

Chemotherapy is not a fun journey, but when you think of the benefits - a total eradication of your cancer cells, or at least a reduction, and an extended life - please remember that this too shall pass and you can do it! You can get through this portion of the treatment! Tomorrow is a brand new day. You go, girl! (and special hoorays for the often-forgotten men who have to go through this disease) For further info on chemo, check out http://www.cancer.gov/cancerinfo/chemoth... http://www.oncolink.com/treatment/articl...

Chemotherapy involves sitting in a "chemo chair", sort of like a recliner, with an armboard on the side. The IV pole is wheeled next to your chair and is attached to your IV(the tubing that attaches to the bags of fluids and your IV line), which is either done by a needle stick in a vein, or through a port-a-cath (discussion later in this section). You basically sit there while the drugs enter your body through the IV line. Sometimes the nurse has to "push" the drugs into the IV line with a short, fat-looking syringe. None of this is painful. With some of the drugs, you experience different sensations - a metallic taste in your mouth, a feeling of warmth when the fluid enters your system, or the need to urinate (It passes; you really don't have to use the restroom).

In most chemotherapy suites, you can eat, read, watch TV or videos or listen to music. They will give you blankets, videos, snacks. They are quite accommodating. Depending on the chemo regime you are on, you may be there an hour or up to three hours. Some chemo is done weekly, others bi-weekly or once every 3-4 weeks. The side effects are no fun, but the treatment itself (except for the needle stick) is easily tolerated.

Most women when told that they should have chemotherapy picture horrific scenes in their minds. Chemotherapy is not a fun event, but it is do-able. Many well-meaning friends will tell you horror stories about someone they know who underwent chemo. Forget it! Today, the oncology team can combat most side effects and though it won't be pleasant, it is, for the most part, tolerable. Remember, you have a start date and a finish date. Reward yourself for each treatment and take it one day, one minute, one treatment at a time - whatever works for you. There is no right or wrong way to go through chemo. It's YOUR chemo - handle it however makes you feel the best.

The first concern is generally hair loss. If you are having CMF(cytoxan, methotrexate and 5-Flu)you probably will not lose your hair. It may thin a bit, but it will stay on your head. The general rule of thumb is that the hair falls out around 14 days after your first treatment. It starts as a few strands on your pillow, then clumps in your comb and wads in the shower drain. The bravest among us take matters into their own hands and shave it all off before the inevitable. Some make it a family affair, with various relatives taking a turn with the buzzer. Others go to the beauty parlor and get a new short hairdo before the alopecia (loss of hair) begins. Whether you decide to beat the chemicals to it and do it yourself or wait for each strand to fall out, make sure your oncologist gives you a prescription for a "cranial prothesis" (fancy name for a wig) before you start chemo.

Insurance companies have to cover a wig as part of your breast cancer treatment. Make an appointment to visit a good wig salon and take an honest, trusted relative or friend with you. This is your big chance! Since most people will know that you are going through chemo, you can either get a wig to match your own hair, or be daring and go long, short, curly, straight, an outrageous color. It's your choice. Wigs come in human hair, synthetic and combination, with human hair being the most expensive and hardest to keep up with. The synthetic wigs are good and easy to take care of. You will also want to have a collect of hats and scarves. Wearing a wig can get tiresome. Suggest to a good friend that you could use a "hat and scarf" shower. It's a chance to get together with your pals, have a fun evening before you begin your chemo adventure and to collect some much-needed headwear. There are many salons that specialize in chemo patients; ask your doctor.

http://www.headcovers.com/ http://www.acewigs.com

If you can not afford a wig, contact the local American Cancer Society in your area. They generally have a supply of wigs for the asking.

http://www.cancer.org

The ACS also has a program known as Look Good, Feel Better. http://www.lookgoodfeelbetter.org

This is a one session meeting with a cosmetologist, who gives you great tips on makeup during chemo and loads you down with great samples from many cosmetic manufacturers. She also carries wigs with her and will style one for you right there, if available. This is a free program.

One more word about hair loss - sometimes the medical staff forgets to tell you that you will lose all your hair - that includes eyebrows, eyelashes, body hair. (The plus is you won't have to shave your legs!) I mention this because some women are shocked when their entire body reverts to newborn baby status - no hair anywhere. Your hair will grow back. It might be a different shade or texture, but it will come back.

Nausea - the other great chemo concern. I am happy to report that with today's anti-emetics (ant-nausea drugs), most women will not have to suffer through continual vomitting. I was queasy a lot; certain food smells triggered my gag reflex and yes, I did throw up a few times, but I never spent hours worshipping the porcelain bowl in my bathroom. Take whatever the oncologist gives you and do not vary from the schedule recommended. I breezed through my first chemo (nausea-wise) and thought I could skip the pill I was supposed to take 12 hours post-chemo. Wrong. I started vomiting almost on the hour. Once I took the pill and it worked its way through my system, I was OK again.

Two words of caution: not all drug stores stock these pills. They are expensive. Make sure you have your prescription in your hand a day or two prior to your first chemo and have the prescription filled and waiting at home for you. If you have limited insurance or funds, ask your oncologist if the drugs are available through a drug-company sponsored program for less cost, or for free. I will list a few of these options at the end of the article.

Second, the same anti-emetic does not work for everyone. If you feel nauseous, or have the dry heaves, or actually vomit, call your doctor and have him give you a different prescription. There are many to choose from. Often, the oncologist recommends the cheapest, most easy-to-find pill. This is your treatment; don't be afraid to make a stink. Ask questions; tell him how you feel; don't give up until you get what works for you. http://www.cancernausea.com/cinv/cinv_in...

There are many other side effects - the most talked about is "hot flashes", with the greatest being fatigue and the most annoying being "chemo brain". There are mouth sores, weight gain/loss, acne, funny tastes in your mouth, constipation, low white cell count...I will cover these in the next article. Take heart! It sounds yuky, but you can do it. With a smile, some prayers, a good support system and being your own best advocate, you will look back at this year in wonderment. Not only will you survive it, but you will grow from the experience. Have faith in yourself.

Hot flashes" can be caused by menopause, whether brought on by the natural aging process or chemically induced, or by hormonal changes within a woman's body. Some women tolerate the "changes" well, while others go bonkers. I was post-menopausal at the time of my diagnosis and was on hormone replacement therapy. Due to my estrogen-positive tumor status, I was immediately taken off HRT and went back into menopause symptoms.

How does one explain it? You get the sweats; you feel flush; you wake up soaking wet in the middle of the night; you want to rip your clothes off when it is 20 below; it is like PMS one hundred times over. I, myself, was a crazy woman. If my husband or kids looked at me crooked, they had a 50-50 chance that I would burst into tears or chew their heads off. Fortunately, my oncologist gave me a small patch to wear, called Catapres. It originally was prescribed as a hypertension medication, but for some women it works for the menopausal symptoms. Others find relief from Paxcil, Zoloft and other drugs. Some women swear by herbal teas, aromatherapy, acupuncture, acupressure. Just make sure that you inform your oncologist of any medications, herbs, vitamins, supplements, etc. that you intend to take before you start your own program. Some of these substances can have quite an adverse effect on the chemo drugs. http://www.nci.nih.gov/cancerinfo/pdq/su...

Some of the other minor side effects of chemo (that not everyone gets) are mouth sores: I got them once and the doctor gave me a gel that you swish in your mouth and spit out and they never returned. It is some type of viscous lidocaine formula. Diarrhea/constipation can be a problem. Ask for a prescription if you really have a problem. Stool softeners, such as Colace, can be beneficial. During chemo, most people get a metallic, odd taste in their mouths. The trick here is to eat whatever you can tolerate. For one round of chemo, I existed on vanilla ice cream and apple sauce for a two week period. Hey, whatever works... Acne can be a problem.

Due to the chemicals coursing through your body, your skin can get pimples, dry, flaky. Make sure to wash with non-perfumed soap, pat gently dry, use moisturizer and lots of skin lotion. Make sure to visit your dentist before you begin chemo. Your gums get inflamed and they don't treat you during chemo unless it is an extreme emergency. Weight gain/loss depends on your body type and whether or not you have to take steroids. No one is ever happy with the weight gain or loss, but you can diet/exercise when chemo is done and get back to your normal weight. You do have to have some "fat" or "skinny" clothes as a back-up for a few months.

"Chemo brain" is hard to describe and is not usually mentioned by the medical staff. It is a combination loss of some memory, depletion of cognitive skills and a huge mix-up of your hormones, feelings and emotions. You type "c-a-t" and it comes out "c-t-a". You know your daughter's name, but can't spit it out. You balance your checkbook three times with different results each time. Don't panic. I did. No one told me about this side effect. I thought I was losing my mind. My secretary said "Good Morning" one day and I burst into tears. I cried for 4 hours straight. Finally, my oncologist told me that the combination of drugs in combo with the "hot flashes" and other side effects were making me an emotional cripple. He gave me Zoloft, an anti-depressant, which I lovingly referred to as my "happy pills". Don't be afraid to discuss your emotional state with the docs. If you don't bring up your feelings, or the state of your sex life, they sure as heck won't. http://www.cancerpage.com/cancernews/can...

Sex can be another sore subject, both figuratively and literally. If your dry skin extends to the vaginal area, a little lubrication, such as Vagisil, will do the trick. If the problem is more in your head, you might want to consider some type of "happy" pill, or visit a counselor. Sex can be a joy - you still feel wanted or it can be a burden - you are so tired and sick that you feel like you are being used. Don't worry. It gets better. Now is the time for all good partners to prove their worth, whether that means hugging and holding only, abstaining from sexual relations, having sex on demand - this is your chemo; it is up to you to tell your partner what you want. They aren't mind readers.

For me, the worst side effect of chemo, was the fatigue. It sneaks up on you gradually. My personal mantra for my entire year of breast cancer treatment was "If I am working, I am not sick". I was too proud, too dumb, too stubborn to allow others to help me. Finally, when I landed in the oncology suite due to dehydration and sheer exhaustion, my favorite nurse, Jean, told me "It's OK to be a patient once in a while". From then on, I asked for help if I needed it. I rested when required. I allowed myself to take a day off. Fatigue wasn't totally debilitating - I worked full-time for most of my 6 months of chemo, but I did take an occasional day off to recuperate. It's your body, listen to it. Don't wallow in self-pity, but don't try to prove you are superwoman either. http://www.intouchlive.com/journals/oncn...

One word of caution - not all remedies work the same for every person, nor does everyone get all the side effects, or even some of them and no one has the same tolerance. There are things that can make the chemo trip a bit easier, but nothing will make it totally stress free. Keep your sense of humor, believe in the power of prayer (either yours or others for your benefit), seek advice, lean on friends and take it one day at a time. Half way through my 8 cycles of chemotherapy, I brought in a cake and some posters of breast cancer-related jokes for my oncology nurses. (There are some great little books of cancer humor). At my last chemo visit, I sprung for a bakery sheet cake that was inscribed with a big pink circle with the word CHEMO in the center and a line slashing through it. It made me feel good to do something for the oncology team and it let them know that not only did I appreciate all their efforts for me, but that I still had my sense of humor and self intact.

Everyone has their own tricks for getting through chemo. I'd love to hear yours. To life!

I recently visited a new doctor (totally unrelated to my cancer history). As he was examining me, he asked about the small, straight scar above my right breast. "It's from my port", I replied. He looked hesitant, so I launched into my "teaching about breast cancer" mode.

When I was about to begin chemotherapy, my oncologist recommended that I have a port implanted.

He explained that the procedure was fairly simple - same day surgery, twilight sleep. Although he cautioned that the site of the incision would feel sore for a few days, he told me that the value of the port would outweigh any discomfort. Since I already liked this doctor and trusted him at first meeting, I agreed.

I made an appointment with my breast surgeon. I did some reach online, spoke to some breast cancer survivors and was convinced that I made the right decision. On the day of the surgery, I arrived at the breast center with my husband, who was told to return in two hours. They ushered me into a procedure room. The anesthesiologist hooked up my IV; they placed me in the recliner; my surgeon and the nurses entered and I went blissfully into la-la land. The surgeon numbed the area, told me to expect some pushing and pulling, but I really was too far out of it to feel anything but a haze. (I always get totally zonked with any amount of anesthesia.)

Before I knew it, they were sitting me up and I had a big bandage over the right side of my chest, above my breast. My husband came to help me dress (my left side was still not cooperating since my mastectomy) and we left for home. Surprise! I was in pain. Now, I had survived a lumpectomy, wide excision, sentinel node biopsy, axillary disseciton, a bout of cellulitis and a mastectomy and I had never been in as much pain as this. Something was wrong.

We stopped at the drug store on the way home to fill the pain medication prescription and I cried in the car while my husband went into the store. He had to practically carry me into the house. I downed two pain pills and slept. The next morning was the same. We called the surgeon. He said to come right in. He checked his handiwork and could find nothing amiss. He sent me for an x-ray to see if somehow my shoulder had gotten dislocated during the surgery. (Now that was a novel idea and one that hadn't been mentioned as a possible danger.) The xray was negative and the surgeon was at a loss for my pain. Since he had been through several surgeries with me, he knew that I was not prone to complaints.

The pain lasted a week and I could do nothing but lay flat. Any movement caused me to wince and the tears to well up. I stayed home until the time for my first chemo appointment. I had made my family look online for possible causes for the pain and one possibility that came up was that the port was lying on a nerve. My surgeon thought I was nuts. The day of my first chemotherapy appointment arrived and I was scared and in pain. The oncology nurse explained the procedure in great detail, swabbed the port with alcohol and told me to take a deep breath while she inserted the needle into it. I held my breath and WOW! relief flooded my body. My port had been on a nerve. Once they accessed the port I feel great. Now my story is not common and most people breeze through the port insertion. Would I do it again? In a heartbeat.

The port is a small roundish rubber-lie stopper that lies just beneath the surface of the skin and is attached to a catheter which is fed into a main artery. This way, the nurse can access the port (it's just a pinch, much less than a needle stick) to take blood and give you your chemo treatments. You don't have to worry about short sleeves or finding a good vein or black and blue arms. You just push aside your collar and the chemo is in!

Right after the surgery the site is just like any other surgery site - red, raw and ugly. Eventually the soreness and newness goes away and you just feel this bump under your skin. For a while, I couldn't get used to it. It didn't hurt, but I was always touching it. This was a foreign object in my body. Watching those who didn't have a catheter endure the nurse searching for a good vein for their blood tests, then waiting for two hours for their chemotherapy, made me glad that I had a port.

Eventually, I forgot it was even there. Since I work in a hospital, I would go down to oncology, have my port accessed for the blood tests, the nurse would tape down the IV hook (the needle that they insert into the port looks like a small meat hook, but really doesn't hurt), I would button my blouse and go back to work for two hours. I would return for chemo, they would insert the IV line into the access site and I was good to go.

After 6 months, I finished chemotherapy and foolishly thought that they would take the port out then and there. My oncologist explained that they would leave it in place for another 6 months "just in case". That's the polite way of saying they wanted to be prepared for a recurrence. After 6 months, several scans, mammos and blood tests, my oncologist told me I could have it removed. I made an appointment with the surgeon.

This time, he did it in his office. He anesthetized the site, made a new incision, removed the device, stitched me back up and that was it. It has now been 3 years since my port was removed and the scar is minimal. It is probably 2 inches across, a nice straight line, and has faded nicely. I can wear necklines which are below the scar and you would have to really stare at my chest, close up, to notice it.

Despite the fact that I had a weird side effect (the port was lying on a nerve), I would highly recommend a port-o-cath to anyone who has to have a lengthy chemotherapy. Even if you have great veins now, chemo destroys them. The procedure for insertion is not long nor terribly painful and the port is worth its weight in gold when you have to go for blood test and/or chemo.

A port is not a requirement for chemotherapy, but it sure does make the whole thing a bit easier. When you are dealing with breast cancer, whatever makes your life more tolerable, I say, go for it!

Good health and the best of life to you all!

RECOMMENDED READING: Dr. Love book - pages 478-491

http://www.cancerbacup.org.uk/info/chemo...

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