When given before surgery, it is typically given for at least 3 to 6 months before surgery and continued after surgery. It may also be given solely after surgery to reduce the risk of recurrence. This is called adjuvant hormonal therapy. Tamoxifen is a drug that blocks estrogen from binding to breast cancer cells. It is effective for lowering the risk of recurrence in the breast that had cancer, the risk of developing cancer in the other breast, and the risk of distant recurrence.
Tamoxifen works in women who have been through menopause as well as those who have not. Tamoxifen is a pill that is taken daily by mouth every day for 5 to 10 years. For premenopausal women, it may be combined with medication to stop the ovaries from producing estrogen. It is important to discuss any other medications or supplements you take with your doctor, particularly any anti-depression medications, as there are some that may interfere with tamoxifen.
Common side effects of tamoxifen include hot flashes and vaginal dryness, discharge, or bleeding. Very rare risks include a cancer of the lining of the uterus, cataracts, and blood clots.
However, tamoxifen may improve bone health and cholesterol levels. Aromatase inhibitors AIs. AIs decrease the amount of estrogen made in tissues other than the ovaries in post-menopausal women by blocking the aromatase enzyme.
This enzyme changes weak male hormones called androgens into estrogen when the ovaries have stopped making estrogen during menopause.
These drugs include anastrozole Arimidex , exemestane Aromasin , and letrozole Femara. All of the AIs are pills taken daily by mouth. Only women who have gone through menopause or who take medicines to stop the ovaries from making estrogen see "Ovarian suppression," below can take AIs. Treatment with AIs, either as the first hormonal therapy taken or after treatment with tamoxifen, may be more effective than taking only tamoxifen to reduce the risk of recurrence in post-menopausal women.
Post-menopausal women with hormone receptor-positive breast cancer can:. Begin hormone therapy with an AI. Begin hormone therapy with tamoxifen and then after a few years, switch to an AI. When an AI is taken after tamoxifen, the drugs are taken for a combined total of 5 to 10 years. The side effects of AIs may include muscle and joint pain, hot flashes, vaginal dryness, an increased risk of osteoporosis and broken bones, and rarely, increased cholesterol levels and thinning of hair.
Research shows that all AIs work equally well and have similar side effects. However, women who have undesirable side effects while taking one AI medication may have fewer side effects with a different AI for unclear reasons. Women who have not gone through menopause and who are not getting shots to stop the ovaries from working see below should not take AIs, as they do not block the effects of estrogen made by the ovaries.
Often, doctors will monitor blood estrogen levels in women whose menstrual cycles have recently stopped, those whose periods stopped with chemotherapy, or those who have had a hysterectomy but their ovaries are still in place, to be sure that the ovaries are no longer producing estrogen.
Ovarian suppression or ablation. Ovarian suppression is the use of drugs to stop the ovaries from producing estrogen. Ovarian ablation is the use of surgery to remove the ovaries. These options may be used in addition to another type of hormonal therapy for women who have not been through menopause. For ovarian suppression, gonadotropin or luteinizing releasing hormone GnRH or LHRH agonist drugs are used to stop the ovaries from making estrogen, causing temporary menopause.
Goserelin Zoladex and leuprolide Eligard, Lupron are types of these drugs. Since they are not very effective for treating breast cancer on their own, they are typically given in combination with other hormonal therapy. They are given by injection every 4 weeks and stop the ovaries from making estrogen.
The effects of GnRH drugs go away if treatment is stopped. For ovarian ablation, surgery to remove the ovaries is used to stop estrogen production. While this is permanent, it can be a good option for women who no longer want to become pregnant, especially since the cost is typically lower over the long term.
Tamoxifen for 5 years, followed by an AI for up to 5 years. This would be a total of 10 years of hormonal therapy. Tamoxifen for 2 to 3 years, followed by 2 to 8 years of an AI for a total of 5 to 10 years of hormonal therapy. In general, women should expect 5 to 10 years of hormonal therapy. The tumor biomarkers and other features of the cancer may also impact who is recommended to take a longer course of hormonal therapy. As noted above, premenopausal women should not take AI medications without ovarian suppression, as they will not lower estrogen levels.
Options for adjuvant hormonal therapy for premenopausal women include the following:. Tamoxifen for 5 years. Then, treatment is based on their risk of cancer recurrence as well as whether or not they have gone through menopause in those 5 years.
If a woman has not gone through menopause after the first 5 years of treatment and is recommended to continue treatment, they can continue tamoxifen for another 5 years, for a total of 10 years of tamoxifen. Alternatively, a woman could start ovarian suppression and switch to taking an AI for another 5 years. If a woman goes through menopause during the first 5 years of treatment and is recommended to continue treatment, they can continue tamoxifen for an additional 5 years or switch to an AI for 5 more years.
Only women who are clearly post-menopausal should consider taking an AI. However, evidence now suggests benefits independent of the use of chemotherapy as well. For women with stage I or stage II cancer with a higher risk of recurrence who may consider also having chemotherapy. For women who cannot take tamoxifen for other health reasons, such as having a history of blood clots, so they can take an AI medication.
Ovarian suppression is not recommended in addition to another type of hormonal therapy in the following situations:. This information is based on ASCO recommendations for adjuvant endocrine therapy for women with hormone receptor-positive breast cancer. Please note this link takes you to another ASCO website.
These treatments are very focused and work differently than chemotherapy. This type of treatment blocks the growth and spread of cancer cells and limits damage to healthy cells. Not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. In addition, research studies continue to find out more about specific molecular targets and new treatments directed at them.
Learn more about the basics of targeted treatments. The first approved targeted therapies for breast cancer were hormonal therapies. Trastuzumab FDA-approved biosimilar forms are available. This drug is approved as a therapy for non-metastatic HER2-positive breast cancer. It is given either as an infusion into a vein every 1 to 3 weeks or as an injection into the skin every 3 weeks.
Currently, patients with stage I to stage III breast cancer see Stages should receive a trastuzumab-based regimen, often including a combination of trastuzumab with chemotherapy, followed by a total of 1 year of adjuvant trastuzumab. This risk is increased if a patient has other risk factors for heart disease or receives chemotherapy that also increases the risk of heart problems at the same time.
These heart problems may go away and can be treated with medication. Pertuzumab Perjeta. This drug is approved for stage II and stage III breast cancer in combination with trastuzumab and chemotherapy. It is given as an infusion into a vein every 3 weeks. Pertuzumab, trastuzumab, and hyaluronidase—zzxf Phesgo. This combination drug, which contains pertuzumab, trastuzumab, and hyaluronidase-zzxf in a single dose, is approved for people with early-stage HER2-positive breast cancer.
It may be given in combination with chemotherapy. It is given by injection under the skin and can be administered either at a treatment center or at home by a health care professional. Neratinib Nerlynx. This oral drug is approved as a treatment for higher-risk HER2-positive, early-stage breast cancer.
It is taken for a year, starting after patients have finished 1 year of trastuzumab. Ado-trastuzumab emtansine or T-DM1 Kadcyla. This is approved for patients with early-stage breast cancer who have had treatment with trastuzumab and chemotherapy with either paclitaxel or docetaxel followed by surgery, and who had cancer remaining or present at the time of surgery. T-DM1 is a combination of trastuzumab linked to a very small amount of a strong chemotherapy.
This allows the drug to deliver chemotherapy into the cancer cell while lessening the chemotherapy received by healthy cells, which usually means that it causes fewer side effects than standard chemotherapy.
T-DM1 is given by vein every 3 weeks. Talk with your doctor about possible side effects of specific medications and how they can be managed. Bone modifying drugs block bone destruction and help strengthen the bone. They may be used to prevent cancer from recurring in the bone or to treat cancer that has spread to the bone.
Certain types are also used in low doses to prevent and treat osteoporosis. Osteoporosis is the thinning of the bones. Denosumab Prolia, Xgeva. An osteoclast-targeted therapy called a RANK ligand inhibitor.
The use of denosumab to lower the risk of breast cancer recurrence is under study. For people with breast cancer that has not spread, receiving bisphosphonates after breast cancer treatment may help to prevent a recurrence. ASCO recommends zoledronic acid Reclast, Zometa or clodronate multiple brand names as options to help prevent a bone recurrence for women who have been through menopause. Clodronate is only available outside of the United States. You may have other targeted therapy options for breast cancer treatment, depending on several factors.
The following drug is used for the treatment of non-metastatic breast cancer. Olaparib Lynparza. This is a type of oral drug called a PARP inhibitor, which destroys cancer cells by preventing them from fixing damage to the cells.
Adjuvant olaparib should be given for 1 year following the completion of chemotherapy, surgery, and radiation therapy if needed. Abemaciclib Verzenio. It is approved as treatment in combination with hormonal therapy tamoxifen or an AI to treat people with hormone receptor-positive, HER2-negative, early breast cancer that has spread to the lymph nodes and has a high risk of recurrence.
Abemaciclib is given twice a day by mouth for up to 2 years. Many of the following drugs are used for advanced or metastatic breast cancer. Alpelisib Piqray. Alpelisib is an option along with the hormonal therapy fulvestrant for people with hormone receptor-positive, HER2-negative metastatic breast cancer that has a PIK3CA gene mutation and has worsened during or after hormonal therapy.
These drugs include abemaciclib Verzenio , palbociclib Ibrance , and ribociclib Kisqali. They are approved for women with ER-positive, HER2-negative advanced or metastatic breast cancer and may be combined with some types of hormonal therapy. They may also be used in conjunction with fulvestrant in endocrine-resistant second-line disease. Lapatinib Tykerb. It may be combined with the chemotherapy capecitabine, the hormonal therapy letrozole, or the HER2 targeted therapy trastuzumab.
Tucatinib Tukysa. Tucatinib, when added to capecitabine chemotherapy and trastuzumab, is approved for the treatment of advanced unresectable or metastatic HER2-positive breast cancer, including cancer that has spread to the brain, in those who have already received 1 or more HER2-targeted therapy.
Unresectable means surgery is not an option. Tucatinib is a tyrosine kinase inhibitor designed to turn off HER2. It is an oral medication that is given twice daily. Sacituzumab govitecan-hziy Trodelvy. The FDA has approved the use of sacituzumab govitecan-hziy for the treatment of people with metastatic triple-negative breast cancer who have already received at least 2 treatments, including 1 treatment for metastatic disease. It is also approved for people with locally advanced triple-negative breast cancer that cannot be treated with surgery.
Sacituzumab govitecan-hziy is an antibody-drug conjugate, which means the antibody attaches to a cancer cell and then delivers the anticancer drug it carries to start destroying the cancer cell.
Sacituzumab govitecan-hziy is given by vein, or intravenously, on days 1 and 8 of every day cycle. Entrectinib Rozyltrek and larotrectinib Vitrakvi. These may be used for breast cancer with an NTRK fusion that is metastatic or cannot be removed with surgery and has worsened with other treatments see Diagnosis. It is a type of drug called a PARP inhibitor, which destroys cancer cells by preventing them from fixing damage to the cells. Talazoparib Talzenna.
It is a PARP inhibitor. Chemotherapy, immunotherapy, hormonal therapy, and targeted therapy may all be given as neoadjuvant treatments for people with certain types of breast cancer. Neoadjuvant chemotherapy, for example, is the treatment usually recommended for people with inflammatory breast cancer.
The doctor will consider several factors including the type of breast cancer that you have, including its grade, stage, and estrogen, progesterone, and HER2 status to guide the decision around whether neoadjuvant chemotherapy should be part of your treatment plan.
ASCO recommends that neoadjuvant systemic therapy be offered to people with high-risk HER2-positive breast cancer or to people with triple-negative breast cancer who would then receive additional drug therapy after surgery, called adjuvant therapy, if cancer still remains. Neoadjuvant therapy may also be offered to reduce the amount of surgery that needs to be performed and allow someone who would otherwise require a mastectomy, for example, to consider having a lumpectomy.
In situations where delaying surgery is unavoidable or preferred such as waiting for genetic test results to guide further treatment options or to allow time for deciding on breast reconstruction options , neoadjuvant systemic therapy may be offered. Your doctor will likely suggest breast imaging after treatment for surgical planning as well as if they believe that the cancer may have progressed despite treatment.
Your doctor will likely use the same type of imaging test in your follow-up care that was most helpful at the time your breast cancer was originally diagnosis.
In general, it is not recommended that blood tests or biopsies be used to monitor response to therapy for people receiving neoadjuvant chemotherapy. Additional drugs, including the chemotherapy drug carboplatin and the immunotherapy drug pembrolizumab see below , may also be recommended in addition to usual chemotherapy drugs to increase the likelihood of having a complete response.
A complete response is when there is no cancer found in the tissue when it is removed during surgery. Talk with your doctor about the potential benefits and risks of receiving carboplatin and pembrolizumab before surgery. People with early-stage 1 cm or less, and no lymph nodes that look abnormal triple-negative breast cancer should not routinely be offered neoadjuvant therapy unless they are participating in a clinical trial.
In cases where a recommendation for chemotherapy can be made without having all the information that is obtained from surgery, such as the actual size of the tumor or the number of involved lymph nodes, any person with HER2-negative, hormone receptor-positive breast cancer can receive neoadjuvant chemotherapy instead of adjuvant chemotherapy.
Meanwhile, for postmenopausal women with large tumors or other reasons why surgery may not be a good option at the time of diagnosis of the cancer, hormonal therapy with an aromatase inhibitor may be offered to reduce the size of the tumor. It may also be used to control the cancer if there is no role for surgery. However, hormonal therapy should not be routinely offered in this situation outside of a clinical trial for premenopausal women with early-stage HER2-negative, hormone receptor-positive breast cancer.
For people with HER2-positive breast cancer that has spread to the lymph nodes or is more than 2 cm in size, neoadjuvant therapy with chemotherapy in combination with the targeted therapy drug trastuzumab should be offered. Another targeted therapy drug against HER2, pertuzumab, may also be used with trastuzumab when given before surgery. However, people with early stage 1 cm or smaller and no abnormal appearing lymph nodes , HER2-positive cancer should not be routinely offered neoadjuvant chemotherapy or drugs that target HER2 such as trastuzumab and pertuzumab outside of a clinical trial.
Immunotherapy, also called biologic therapy, is designed to boost the body's natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. The following drugs, which are a type of immunotherapy called immune checkpoint inhibitors, are used for recurrent and advanced or metastatic breast cancer. Pembrolizumab is also used for high-risk, early-stage disease. Pembrolizumab Keytruda. You may be able to eat normally throughout chemotherapy or your eating habits may change because of side effects.
Find out more about diet during treatment. The evidence is not clear whether supplements such as vitamins, particularly high-dose antioxidants including vitamins A, C and E, co-enzyme Q10 and selenium , are harmful or helpful during chemotherapy.
You can still have sex during treatment. Most treatment teams will advise using barrier methods of contraception, such as condoms during treatment, and for a few days after chemotherapy is given. Your specialist will usually recommend barrier methods of contraception, such as condoms. The contraceptive pill is not usually recommended because it contains hormones.
Emergency contraception such as the morning after pill can still be used. Find out more about how breast cancer and its treatment can affect sex and intimacy and read our tips on how to manage these changes. Live vaccines include mumps, measles, rubella German measles , polio, BCG tuberculosis , shingles and yellow fever. Live vaccines contain a small amount of live virus or bacteria.
If you have a weakened immune system, which you may do during chemotherapy, they could be harmful. Talk to your GP or treatment team before having any vaccinations.
If anyone you have close contact with needs to have a live vaccine speak to your treatment team or GP. They can advise what precautions you may need to take depending on the vaccination. Anyone at risk of a weakened immune system, and therefore more prone to infection, should have the flu vaccine. This includes people due to have, or already having, chemotherapy.
Talk to your chemotherapy team or breast care nurse about the best time to have your flu jab. People having chemotherapy are advised to speak to their treatment team before having a coronavirus Covid vaccination. Find out more about the coronavirus vaccine. Not knowing what to expect can be very distressing. Many people worry about the side effects they might get. But most side effects can be controlled.
You should be told what side effects to report as well as details of who to contact, day or night, if you have any concerns or are unwell. Your chemotherapy team and breast care nurse can help with any questions you have. You can also call us free on for information and support. On our online Forum , you can find people going through treatment at the same time as you on the chemotherapy monthly threads.
You can also speak to someone who has had chemotherapy through our Someone Like Me service. Most side effects occur during treatment and begin to go away shortly after treatment ends. Others can last for months or even years. Learn about easing worries over side effects of chemotherapy. Learn about short-term side effects of chemotherapy.
Learn about long-term side effects of chemotherapy. Research is ongoing to improve chemotherapy. New drugs and ways to help guide chemotherapy decisions are under study in clinical trials. Learn about emerging areas in chemotherapy for early and locally advanced breast cancer. Learn about emerging areas in treatment for metastatic breast cancer. Learn about clinical trials. Learn more about talking with your health care provider. It may be helpful to download and print Susan G.
There are other Questions to Ask Your Doctor resources on many different breast cancer topics you may wish to download. They are a nice tool for people recently diagnosed with breast cancer, who may be too overwhelmed to know where to begin to gather information.
For those with metastatic breast cancer, chemotherapy is used to kill cancer cells that have spread from the breast to other parts of the body. Learn more about treatment for metastatic breast cancer. Although the exact treatment for breast cancer varies from person to person, guidelines help ensure high-quality care. These guidelines are based on the latest research and agreement among experts.
Breast cancer treatment is most effective when all parts of the treatment plan are followed as prescribed. Although most side effects go away shortly after chemotherapy ends, preventing or treating symptoms can help you complete your course of chemotherapy. Talk with your health care provider about any side effects you have. Your provider may be able to prescribe medications to treat your side effects or change your treatment plan to reduce them. Learn more about the side effects of chemotherapy.
Learn more about the importance of following your breast cancer treatment plan. Most chemotherapy drugs for breast cancer are given by vein through an IV in an outpatient setting at a hospital or clinic. If you need a ride to and from treatment, or have child care or elder care needs that make getting to treatments difficult, there may be resources available. These may be ways for them to get involved.
Sometimes, there are programs that help with local or long-distance transportation and lodging if you need a place to stay overnight during treatment. There are also programs that help with child care and elder care costs. If you have trouble remembering to take oral chemotherapy or medications to treat side effects, a daily pillbox or setting an alarm on your watch or mobile device you may be able to download an app may help [ 1 ]. Medicare and many insurance companies offer prescription drug plans.
One may already be included in your policy or you may be able to buy an extra plan for prescriptions. Most doctors will check your heart function with a test like an echocardiogram an ultrasound of the heart or a MUGA scan before starting one of these drugs. They also carefully control the doses, watch for symptoms of heart problems, and may regularly repeat heart tests during treatment. If the heart function begins to worsen, treatment with these drugs will be temporarily or permanently stopped.
Still, in some people, signs of damage might not appear until months or years after treatment stops. Many drugs used to treat breast cancer, including taxanes docetaxel, paclitaxel, and protein-bound paclitaxel , platinum agents carboplatin, cisplatin , vinorelbine, eribulin, and ixabepilone, can damage nerves in the hands and arms and feet and legs. This can sometimes lead to symptoms in those areas like numbness, pain, burning or tingling sensations, sensitivity to cold or heat, or weakness.
In most cases these symptoms go away once treatment is stopped, but in some women it might last a long time or may become permanent. There are medicines that could help with these symptoms.
Certain chemo drugs, such as capecitabine and liposomal doxorubicin, can irritate the palms of the hands and the soles of the feet. This is called hand-foot syndrome. Early symptoms include numbness, tingling, and redness. If it gets worse, the hands and feet can become swollen and uncomfortable or even painful. The skin may blister, leading to peeling or even open sores.
There is no specific treatment, although some creams or steroids given before chemo may help. These symptoms gradually get better when the drug is stopped or the dose is lowered. The best way to prevent severe hand-foot syndrome is to tell your doctor when symptoms first come up, so that the drug dose can be changed or other medicines can be given. Many women who are treated with chemotherapy for breast cancer report a slight decrease in mental functioning. They may have some problems with concentration and memory, which may last a long time.
Although many women have linked this to chemo, it also has been seen in women who did not get chemo as part of their treatment. Still, most women function well after treatment.
In studies that have found chemo brain to be a side effect of treatment, the symptoms most often last for a few years. Very rarely, certain chemo drugs can cause diseases of the bone marrow, such as myelodysplastic syndromes or even acute myeloid leukemia , a cancer of white blood cells.
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