Julie R. Gralow, MD, is director of breast medical oncology at the University of Washington and Fred Hutchinson Cancer Research Center in Seattle.
Q: Do all breast cancer patients have to have chemotherapy?
A: No, chemo is used less and less. Five years ago, we considered chemo for most breast cancer patients; now it's only about 20%. There are tests to help decide if someone needs chemo or not. But we also look at a tumor's grade and whether the cancer is estrogen-receptor negativein which case, it won't respond to hormone therapy, but it may respond to chemo.
Q: What does chemotherapy do?
A: Chemotherapy disrupts the ability of cells to survive and grow by interfering with DNA. Cancer cells are more sensitive to chemo since they are usually the most active cells in the body, but normal cells are disrupted toothat's what causes you to experience side effects. Side effects can include hair loss, nausea, irritation of the gut, or a decrease in blood cell counts that can lead to infection, anemia, fatigue, or bleeding.
Q: I've heard chemo isn't as toxic as it used to be. Is that true?
A: Yes, chemo is generally a lot easier to tolerate now than it was 20 years ago, because with lower doses and less toxic combinations, there are fewer and less difficult side effects. There are also lots of drugs you can take now to fight the nausea, vomiting, and low-white-blood-cell counts. And on some of the newer chemo meds, especially those used to treat relapsed, metastatic breast cancer, you may even keep your hair.
Q: If I have to get chemo, how often and for how long will I be treated?
Q: What are the chances I'm a candidate for hormone therapy?
A: Between 75% and 80% of breast cancer is estrogen-receptor-positive, which means it responds to hormone therapy because estrogen encourages it to grow. (If you're eligible and opt to take the treatment, you'll probably stay on it for a period of five to ten years, after completing chemotherapy and other therapies.)
Q: What's the difference between the two different classes of hormone therapy?
A: The choice is between aromatase inhibitors (AIs)such as exemestane (Aromasin), anastrozole (Arimidex), and letrozole (Femara)and selective estrogen receptor modulators (SERMs), such as tamoxifen. AIs don't work if you have functioning ovaries, so in younger women, tamoxifen is the standard choice, though we could use drugs to temporarily shut down the ovaries. After menopause, it's an equal choice between AIs and tamoxifen. I prefer the AIs, but they can cause bone loss and osteoporosis, joint and muscle aches, and an increase in cholesterol. Tamoxifen can cause blot clots, and it carries a tiny increase of uterine cancer risk. These risks increase with age.
Q: If I'm premenopausal, can I still have children after hormone therapy?
A: Yes, most women remain fertile. Premenopausal women who take anti-estrogen therapy may, however, start menopause at a different age than they might have without. Premenopausal women don't normally take aromatase inhibitors because of the fertility issue, but if we use ovarian-blocking hormones, the function usually returns quickly after stopping treatment.
Q: What's Herceptin?
A: Herceptin (trastuzumab), an intravenous medication, is available to the 20% to 25% of patients whose breast cancer tests HER2-positive when it's biopsied. Herceptin works by binding to the HER2/neu protein on the surface of a cancer cell and shutting down the cell's ability to grow. It works very well with chemotherapy. However, in a small number of patients, it can hurt the pumping ability of the heart, especially when combined with certain chemotherapy drugs, such as Adriamycin. This is frequently reversible when Herceptin treatment is stopped.
Q: When and for how long do I take Herceptin?
A: When taken at the same time as chemotherapy, Herceptin is usually taken weekly. If taken by itself, it's once every three weeks. In early-stage breast cancer, you take Herceptin for a year.
Q: Do some people choose not to take hormone therapy or Herceptin because of side effects?
A: Yes, that's a deciding factor for some patients. The idea is to weigh the side effects against how well a drug is expected to prevent cancer recurrences. Usually the benefits win, but some patients do opt out.
Q: What kind of follow-up will I be doing with my doctor after I'm done with treatment?
A: You'll probably see your doctor every three or four months for the first two years, then every four to six months for five years, then annually after that. We'll do a breast exam each time, unless you have had a double mastectomy, in which case we'll do a mammogram or an MRI. Mostly what we're looking for is side effects of your treatment, such as lymphedema or neuropathy. We'll also do blood work to make sure there's no recurrence of the cancer.