Treatment Update: Breast Cancer With Highlights From the 2021 San Antonio Breast Cancer Symposium
Each year in the United States, there are nearly 290,000 diagnoses of breast cancer. In recent years, the number of effective treatments for breast cancer has increased.
Breast cancer is not just one disease. There are several different subtypes, each with unique features. Doctors are able to tailor treatments according to the characteristics of these specific subtypes.
Both men and women can be diagnosed with breast cancer, with men representing about 1 percent of all breast cancer cases. Treatment updates often refer only to women patients, but there are risks across other populations, including men and trans women undergoing hormone treatment. This booklet is for anyone facing a breast cancer diagnosis. Your health care team will tailor a treatment plan that best fits your situation.
In this update, we talk about current available breast cancer treatments and new medicines in development. We also describe how to cope with possible treatment side effects and how to communicate most effectively with your health care team.
Types of Breast Cancer
Hormones and other chemical messengers in the bloodstream can attach to specialized proteins (called receptors) and fuel the growth of cancer cells. These receptors may lie within or on the surface of cancer cells.
There are four main subtypes of breast cancer, based on the presence or absence of specific receptors:
Hormone receptor (HR) positive. Cancers that have receptors for estrogen (ER-positive) and/or progesterone (PR-positive) are considered hormone-positive. Nearly two-thirds of ER-positive cancers are also PR-positive.
HER2-positive. This type of breast cancer contains an overabundance of a protein called human epidermal growth factor receptor 2 (HER2). About half of HER2-positive cancers are also HR-positive.
HER2-low. Breast cancers that do not contain an overabundance of the HER2 protein.
Triple-negative (TNBC). Breast cancers that do not have receptors for estrogen or progesterone and do not contain an overabundance of the HER2 protein.
A mammogram is an X-ray picture of the breast. It is often the first test used to check for breast cancer in those who have a lump or another sign of tumor growth. A mammogram is also used as a screening test when there are no apparent signs or symptoms of breast cancer. If the doctor sees anything suspicious, additional tests are conducted.
Breast ultrasound uses sound waves to examine the breast. This is another common tool in evaluating breast lumps and other abnormal findings, especially in young patients who have breasts that are considered dense (have a relatively high amount of glandular tissue and fibrous connective tissue and a relatively low amount of fatty tissue).
Magnetic Resonance Imaging (MRI)
Breast MRI uses magnetic waves to evaluate breast tissue and breast abnormalities. For some individuals at high risk of developing breast cancer (such as anyone with strong family histories of breast cancer and/or BRCA or other gene mutations), breast MRI may be recommended as part of cancer screening. Some individuals are candidates for breast MRI for surveillance after they have completed breast cancer treatment.
Tests performed on tumor samples provide doctors with valuable information that helps guide treatment decisions. One such test is a biopsy, in which a doctor uses a needle to remove a tissue sample from the tumor so that it can be examined under a microscope. Some breast biopsies require surgery (known as an excisional biopsy).
Biopsies can help doctors determine whether the tumor is non-invasive (has not spread outside the milk duct or gland, where breast tumors usually begin) or invasive (has spread outside the duct or gland into nearby breast tissue). Another important piece of information that can be learned from the biopsy is the tumor’s hormone receptor status, which indicates whether or not the tumor’s growth is driven by hormones (ER-positive, PR-positive or HER2-positive).
There are also “liquid” biopsies that can be used in the diagnosis of breast cancer. In a liquid biopsy, the DNA that is shed into the blood by breast cancer tumors is collected via a blood test and examined for cancer cells.
In a staging surgery, the doctor removes the tumor to determine the size and microscopic patterns of cancer cells to assess how likely the cancer is to return. The surgeon also removes one or more lymph nodes in the underarm near the affected breast to see if they contain cancer cells. Lymph nodes are part of the immune system and can be one of the first sites where cancer cells spread in cases of early breast cancer.
In certain cases of early-stage breast cancer, a test called a “genomic assay” or “gene expression profile” may be used. This test is designed to detect several types of genes or groups of genes in the cancerous cells. The expression profile of these genes can help doctors determine how likely it is that a person with early-stage breast cancer will have the cancer return after completing treatment. (A patient’s recommended treatment is dependent on the type of cancer as well as other factors.) Having certain genes can also be associated with a higher likelihood of the cancer responding well to a particular drug.
Genomic assays provide a quantitative (numbers-based) analysis that can help patients and their doctors better understand the prognosis and decide if additional treatment should be pursued. Commonly used genomic assays include the Oncotype DX score, MammaPrint and others.
Treatment recommendations are individualized, taking into consideration the biology of the cancer, its stage and the overall health of the individual.
Treatment for breast cancer usually includes a combination of surgery, radiation and drug therapy. Surgery and radiation focus on the disease in the breast and lymph nodes, and are referred to as “locoregional” therapies.
Drugs (medical therapies) focus on eliminating breast cancer cells that have traveled through the bloodstream and invaded other organs such as the liver, lungs or bones. Medical therapies are also often used in early-stage breast cancer to destroy microscopic cancer cells hiding in other organs, reducing the risk of advanced-stage breast cancer.
Treatment for breast cancer that has metastasized (spread beyond the breast and lymph nodes as seen on tests such as CAT scans, PET scans or bone scans) generally focuses on drugs that circulate to wherever cancer cells are located. However, localized treatment to specific metastatic lesions (collections of cancer cells) may sometimes be useful.
In the past, doctors thought that mastectomy (full removal of the breast) was the best way to improve the chances that the cancer would not return. However, mastectomy does not completely eliminate the chances of the tumor coming back. For many, lumpectomy (removal of the tumor and surrounding tissue but preserving the breast) plus radiation is equally effective. Lumpectomy also has the advantage of offering a better cosmetic result and a shorter recovery time than mastectomy. In either a mastectomy or a lumpectomy, the surgeon often removes one or more lymph nodes in the underarm near the affected breast to see if they contain cancer cells. In some cases, the surgeon will remove only the sentinel lymph node(s), the first few lymph node(s) into which breast cancer cells may have spread. If the sentinel lymph node is cancer-free, chances are that other lymph nodes are also unaffected and can be left in place, reducing the risk of lymphedema, a painful swelling of the arm that sometimes results from the removal of lymph nodes.
Radiation to the entire breast, usually given over 6 weeks, has been the standard of care for those who have been treated with lumpectomy. Recent trials have shown that, in some cases, higher daily doses of radiation given over 3 weeks (with the same total combined dose of radiation) are as effective as the standard approach, with similar potential side effects.
There are other radiation options that can also be considered:
- Accelerated partial breast irradiation (APBI) is given only to the area of the breast in which the cancer is present. APBI delivers more radiation in a shorter treatment period.
- Brachytherapy uses tiny radioactive pellets or catheters, surgically inserted during a lumpectomy, to deliver a localized dose of radiation.
Some people who have undergone a mastectomy will require post-surgery radiation. Factors that increase the likelihood that radiation after a mastectomy will be required include larger tumor size, the presence of affected lymph nodes and positive margins (cancer cells at the edge of the removed tissue).
Drug therapy is an important treatment option for many who have breast cancer. These therapies work by traveling through the bloodstream to destroy cancer cells.
Chemotherapy can be an important part of treatment for both early stage and metastatic breast cancer. In particular, triple-negative breast cancer (TNBC) often responds well to chemotherapy. Based on clinical trials over many years, doctors have learned how to use chemotherapy more effectively, either alone or in combination with other treatments. Doses and schedules of chemotherapy have been refined so that the most benefits are received from treatment with the fewest possible side effects.
Chemotherapy can be used before surgery (preoperative, also called neoadjuvant therapy) to try to shrink the tumor so the surgery can be less extensive, or after surgery (adjuvant) to try to kill any remaining cancer cells. In some cases, the use of preoperative chemotherapy can also provide the doctor with information on how sensitive the cancer cells are to the treatment, which may guide further therapy. It can also be used in cases where the breast cancer has metastasized.
The most common chemotherapy drugs used to treat breast cancer include:
Anthracyclines, such as doxorubicin (Adriamycin), pegylated liposomal doxorubicin (Doxil, Caelyx) and epirubicin (Ellence).
Antimetabolites, such as capecitabine (Xeloda) and gemcitabine (Gemzar).
Antimicrotubule agents, such as ixabepilone (Ixempra), eribulin (Halaven) and Vinorelbine (Navelbine).
Platinum agents, such as platitinol (Cisplatin) and carboplatin (Paraplatin).
Taxanes, such as paclitaxel (Taxol), docetaxel (Taxotere) and albumin-bound paclitaxel (Abraxane).
Hormone (Endocrine) Therapy
Doctors will often recommend hormone therapy as a treatment for early stage and metastatic ER-positive and/or PR-positive breast cancer. Hormone treatments work in different ways. Some are designed to prevent estrogen from attaching to receptors in breast cancer cells, while others are designed to reduce the level of hormones that circulate in the body. By blocking the effects of estrogen or lowering levels of estrogen, these treatments deprive tumor cells of the stimulation that fuels their growth.
The most common hormone therapies used to treat ER-positive or PR-positive breast cancer include:
Tamoxifen (Soltamox, Nolvadex) is an estrogen-blocking treatment given to both pre- and postmenopausal individuals with breast cancer. Studies have shown that taking tamoxifen for five years following surgery reduces the chance of the cancer recurring by fifty percent. For anyone with cancer in one breast, tamoxifen also lowers the risk of a new tumor developing in the unaffected breast.
Some studies have shown that taking tamoxifen for ten years can be even more beneficial for those at higher risk of recurrence. For those with metastatic breast cancer, tamoxifen can shrink the tumor, prolong progression-free survival (the time in which the tumor does not grow) and improve overall survival.
Tamoxifen has also been approved as chemoprevention, reducing the chance of ER-positive breast cancer developing in healthy pre- or postmenopausal individuals who are at high risk for breast cancer, with the preventive benefits of the drug extending for many years beyond when the drug is taken.
Healthy individuals who are at high risk for developing breast cancer should talk with their doctors about whether taking tamoxifen for breast cancer prevention is a good option for them. The doctor will consider multiple factors such as age, family history, biopsy results and reproductive history.
Aromatase inhibitors (AIs), another type of hormone therapy, are given to postmenopausal individuals with early-stage ER-positive breast cancer to help prevent cancer from returning after surgery. In some situations, AIs can also be used for the treatment of premenopausal individuals, along with medications to artificially induce menopause (see next section: “Ovarian Suppression”). AIs block the action of an enzyme called aromatase, cutting off the supply of estrogen (estrogen can stimulate tumor growth). AIs are also commonly used to treat metastatic breast cancer, sometimes in combination with targeted therapies. They have also shown effectiveness in breast cancer prevention.
The AIs primarily used to treat breast cancer are anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin). Taking AIs for five years (either alone or after five years of tamoxifen) can help reduce recurrence in postmenopausal individuals with ER-positive breast cancer.
Fulvestrant (Faslodex) is another estrogen-blocking drug. It works by attaching to estrogen receptors, changing their shape and preventing the receptors from working properly, which slows the growth of breast cancer cells. Fulvestrant is given as a monthly injection and is approved for postmenopausal individuals with metastatic breast cancer.
Ovarian Suppression (Combined with Tamoxifen or Aromatase Inhibitors)
The estrogen produced by the ovaries can fuel tumor growth. Ovarian suppression uses drug therapy or surgery to stop the ovaries from producing estrogen. Some younger, premenopausal individuals with hormone receptor-positive breast cancer may benefit from treatment with ovarian suppression drugs, combined with tamoxifen or an aromatase inhibitor. Ovarian suppression drugs include leuprolide (Lupron) and goserelin (Zoladex).
Targeted therapy focuses on specific molecules and cell mechanisms thought to be important for cancer cell survival and growth, taking advantage of what researchers have learned in recent years about how cancer cells grow.
A number of targeted therapies have been developed for the treatment of breast cancer:
Trastuzumab (Herceptin) is the standard treatment for HER2-positive breast cancer. Typically taken for one year in the treatment of early-stage breast cancer, trastuzumab can also be given over longer periods to treat cases of metastatic disease.
Lapatinib (Tykerb) is able to block HER2 signals from within cancer cells, and has shown to be effective in treating cases where HER2-positive breast cancer has returned, spread or continued growing after treatment with trastuzumab and chemotherapy.
Pertuzumab (Perjeta) was approved by the U.S. Food and Drug Administration (FDA) in 2012 for metastatic HER2-positive breast cancer and in 2013 as a neoadjuvant treatment option for HER2-positive breast cancer when used in combination with trastuzumab and chemotherapy (docetaxel or paclitaxel). In December 2017, pertuzumab’s approval was extended for use as an adjuvant treatment for HER2-positive breast cancer, also in combination with trastuzumab and chemotherapy.
Ado-trastuzumab emtansine (Kadcyla), an antibody drug conjugate also known as T-DM1, is a combination of trastuzumab and a chemotherapy drug used to treat HER2-positive metastatic breast cancer. Additionally, in May 2019 the FDA approved T-DM1 for the treatment of those with early-stage HER2-positive breast cancer whose tumors do not completely respond to neoadjuvant treatments.
Trastuzumab deruxtecan (Enhertu), an antibody drug conjugate, was approved in December 2019 for the treatment of unresectable (inoperable) or metastatic HER2-positive breast cancer following two or more anti-HER2-based regimens. In May 2022, the FDA updated the approval of trastuzumab deruxtecan for the treatment of metastatic HER2-positive breast cancer following anti-HER2 therapy.
Neratinib (Nerlynx). In July 2017, the FDA approved the tyrosine kinase inhibitor neratinib as an adjuvant therapy to further reduce recurrence in those with early-stage HER2-positive breast cancer who have finished at least one year of post-surgery therapy with trastuzumab.
Tucatinib (Tukysa). In April 2020, the FDA approved tucatinib, in combination with trastuzumab and the chemotherapy capecitabine, for the treatment of HER2-positive metastatic breast cancer.
Margetuximab-cmkb (Margenza). Margetuximab-cmkb, in combination with chemotherapy, is used for the treatment of HER2-positive metastatic breast cancer that was previously treated with at least two anti-HER2 regimens. Margetuximab-cmkb was approved by the FDA in December 2020.
Sacituzumab govitecan-hziy (Trodelvy), an antibody drug conjugate, was approved by the FDA in April 2021 for the treatment of unresectable locally advanced or metastatic triple-negative breast cancer that was previously treated with two or more therapy regimens, at least one of them for metastatic disease.
Other therapies that have been developed for use based on individual circumstances include:
mTOR inhibitors. Everolimus (Afinitor) is a targeted therapy that works inside cancer cells to restore their sensitivity to anti-estrogen therapies such as AIs. In treating breast cancer, everolimus seems to help hormone therapy work more effectively, but it may cause increased side effects. Taken once daily with the AI exemestane, everolimus treats advanced hormone receptor-positive, HER2-negative breast cancer in postmenopausal cases where the cancer has continued to grow after treatment with another AI.
CDK4/6 inhibitors. These therapies are designed to interrupt enzymes that promote the growth of cancer cells. The CDK4/6 inhibitors used in treating ER-positive, HER2-negative metastatic breast cancer are abemaciclib (Verzenio), palbociclib (Ibrance) and ribociclib (Kisqali). Each of these medications can be given in combination with hormone therapy, such as the AI letrozole or the hormone therapy fulvestrant. Abemaciclib can also be used as a monotherapy (a medication given alone).
PARP inhibitors. PARP is a type of enzyme that helps repair DNA. In cancer treatment, PARP inhibitors are used to prevent cancer cells from repairing their damaged DNA. This prevention can cause the cancer cells to die, especially those with defective DNA repair pathways, such as BRCA1/2-associated breast cancers.
Talazoparib (Talzenna) is approved for the treatment of BRCApositive, HER2-negative metastatic breast cancer. Olaparib (Lynparza) is approved for the treatment of BRCA-positive, HER2-negative metastatic breast cancer that was previously treated with chemotherapy, and in the adjuvant (after surgery) setting for patients with high-risk triple negative or HR-positive breast cancer.
Immunotherapy. In November 2020, the FDA granted accelerated approval to pembrolizumab (Keytruda) in combination with chemotherapy for the treatment of locally recurrent unresectable (inoperable) or metastatic triple-negative breast cancer whose tumors express high levels of the protein PD-L1. In July 2021, the FDA approved pembrolizumab for the treatment of high-risk, early-stage triple-negative breast cancer in combination with chemotherapy as a preoperative treatment and then continued as a monotherapy after surgery.
PIK3CA inhibitor. In May 2019, the FDA approved alpelisib (Piqray), in combination with the endocrine therapy fulvestrant, to treat HR-positive, HER2-negative, PIK3CA-mutated metastatic breast cancer following treatment with an endocrine-based therapy.
Antibody-drug conjugate. In April 2020, the FDA approved sacituzumab govitecan-hziy (Trodelvy) for metastatic triple-negative breast cancer that had been treated by at least two prior therapies.
This section presents highlights from the 2021 San Antonio Breast Cancer Symposium, which took place December 7-10 in San Antonio, Texas as both a virtual and in-person event. The information includes new findings on a number of currently used treatments, as well as promising new treatments that researchers continue to study in clinical trials.
Some of these new treatments are in the earliest phases of research and may not be available to the general public outside of a clinical trial. The information is intended for discussion with your doctor. They can let you know if these research findings affect your treatment plan and whether a clinical trial might be right for you.
Benefits of ovarian suppression supported in updated trial results
Updates from the SOFT and TEXT trials showed the benefits of ovarian suppression were sustained long-term for premenopausal women with early-stage HR-positive breast cancer. A separate meta-analysis of four randomized trials also found that aromatase inhibitors were superior to tamoxifen when combined with ovarian suppression.
What Patients Need to Know
The risk of breast cancer recurrence was reduced by approximately 20 percent when aromatase inhibitors (rather than tamoxifen) were combined with ovarian suppression.
Chemotherapy can be skipped in certain cases of HR-positive, HER2-negative breast cancer
Initial results from the RxPONDER trial showed that certain postmenopausal women with HR-positive, HER2-negative breast cancer can safely skip chemotherapy after surgery.
What Patients Need to Know
In cases where the breast cancer has spread to three or fewer lymph nodes and has a 21-gene recurrence score of 25 or lower, post-surgery treatment can safely consist of endocrine therapy alone.
Adding abemaciclib to endocrine therapy has benefit in HR-positive, HER2-negative breast cancer
Long-term follow-up of the phase III monarchE trial showed the benefit of adding abemaciclib to endocrine therapy in the post-surgery treatment of early-stage high-risk HR-positive, HER2-negative breast cancer. Abemaciclib is a CDK4/6 inhibitor.
What Patients Need to Know
This benefit was seen primarily in patients with Ki-67 index or with 4 or more positive lymph nodes. Tumors with a high Ki-67 index have a large number of proliferating (growing and dividing) cells and are likely to grow more quickly.
Analyses of MONALEESA trial showed benefit of adding ribociclib to endocrine therapy
The widespread benefit of adding ribociclib to endocrine therapy in the first-line (initial) treatment of HR-positive, HER2-negative advanced breast cancer was shown in further analyses of the MONALEESA trial. Ribociclib is a CDK4/6 inhibitor.
What Patients Need to Know
The benefit was in comparison to endocrine therapy alone, and was seen across multiple subgroups.
Treatment approaches compared in HER2-positive breast cancer
The DESTINY-Breast03 phase III trial showed that, compared to trastuzumab emtansine, trastuzumab deruxtecan demonstrated a higher progression-free survival (PFS) and objective response rate (ORR) in the treatment of certain cases of HER2-positive breast cancer.
What Patients Need to Know
The benefit was seen in HER2-positive unresectable (inoperable) and/or metastatic HER2-positive breast cancer previously treated with trastuzumab (a targeted therapy) and a taxane (a type of chemotherapy).
Adding pembrolizumab to chemotherapy as treatment for triple-negative breast
The final analysis of the KEYNOTE-355 trial showed a statistically significant reduction in the risk of death when pembrolizumab was added to chemotherapy as a first-line treatment of metastatic triple-negative breast cancer (TNBC) that is strongly positive for the protein PD-L1.
What Patients Need to Know
These findings provide support for the combination of pembrolizumab and chemotherapy as a standard of care for the treatment of PD-L1–positive TNBC.
Targeted therapy showed encouraging results in the treatment of metastatic TNBC
Updated data from the phase I TROPION-PanTumor01 trial showed the investigational drug datopotamab deruxtecan had encouraging durable tumor response and disease control in the treatment of metastatic triple-negative breast cancer that had progressed after standard therapy.
What Patients Need to Know
Datopotamab deruxtecan is an antibody drug conjugate (ADC), a type of targeted therapy. It remains under investigation.
All cancer treatments can cause side effects. It’s important that you report any side effects that you experience to your health care team so they can help you manage them. Report them right away—don’t wait for your next appointment. Doing so will improve your quality of life and allow you to stick with your treatment plan.
It’s important to remember that not all patients experience all side effects, and patients may experience side effects not listed here. There are certain side effects that may occur across different treatment approaches. Following are tips and guidance for managing these side effects.
Managing Digestive Tract Symptoms
Nausea and vomiting
- Avoid food with strong odors as well as overly sweet, greasy, fried or highly seasoned food.
- Eat meals that are chilled, which often makes food more easily tolerated.
- Nibble on dry crackers or toast. These bland foods are easy on the stomach.
- Having something in your stomach when you take medication may help ease nausea.
- Drink plenty of water. Ask your doctor about using drinks such as Gatorade that provide electrolytes. Electrolytes are body salts that must stay in balance for cells to work properly.
- Over-the-counter medicines such as loperamide (Imodium A-D and others) and prescription drugs are available for diarrhea but should be used only if necessary. If the diarrhea is bad enough that you need medicine, contact a member of your health care team.
- Choose foods that contain soluble fiber, like beans, oat cereals and flaxseed, and high-pectin foods such as peaches, apples, oranges, bananas and apricots.
- Avoid foods high in refined sugar and those sweetened with sugar alcohols such as sorbitol and mannitol.
Loss of appetite
- Eating small meals throughout the day is an easy way to take in more protein and calories, which will help maintain your weight. Try to include protein in every meal.
- To keep from feeling full early, avoid liquids with meals or take only small sips (unless you need liquids to help swallow). Drink most of your liquids between meals.
- Keep high-calorie, high-protein snacks on hand such as hard-boiled eggs, peanut butter, cheese, ice cream, granola bars, liquid nutritional supplements, puddings, nuts, canned tuna or trail mix.
- If you are struggling to maintain your appetite, talk to your health care team about whether appetite-building medication could be right for you.
Fatigue (extreme tiredness not helped by sleep) is one of the most common side effects of many cancer treatments. If you are taking a medication, your doctor may lower the dose of the drug, as long as it does not make the treatment less effective. If you are experiencing fatigue, talk to your doctor about whether taking a smaller dose is right for you.
There are a number of other tips for reducing fatigue: * Take several short naps or breaks during the day. * Take walks or do some light exercise, if possible. * Try easier or shorter versions of the activities you enjoy. * Ask your family or friends to help you with tasks you find difficult or tiring.
There are also prescription medications that may help, such as modafinil. Your health care team can provide guidance on whether medication is the right approach for your individual circumstances.
There are a number of options for pain relief, including prescription and over-the-counter medications. It’s important to talk to a member of your health care team before taking any over-the-counter medication to determine if it is safe and to make sure it will not interfere with your treatment. Many pain medications can lead to constipation, which may make your pain worse. Your doctor can prescribe medications that help to avoid constipation.
Physical therapy, acupuncture and massage may also be of help in managing your pain. Consult with a member of your health care team before beginning any of these activities.
Hormone therapies and chemotherapy can cause bone loss, which increases the risk of osteoporosis (a condition in which bones become weak and brittle). Talk with your health care team about how exercise and changes in your diet may help keep your bones healthy, and about the medications available for bone health:
- Bisphosphonates such as zoledronic acid (Zometa and others) slow the process by which bone wears away and breaks down. These medications belong to a class of drugs called osteoclast inhibitors.
- RANK ligand inhibitors block a factor in bone development known as RANK ligand, which stimulates cells that break bone down. By blocking RANK ligand, these drugs increase bone density and strength. Currently, the only drug approved in this class is denosumab (Xgeva, Prolia). Like bisphosphonates, RANK ligand inhibitors are a type of osteoclast inhibitor.
Breast cancer treatments can lead to menopausal symptoms, such as hot flashes and night sweats. If you are experiencing these side effects, speak with your health care team about ways to cope with them. There are several medications that potentially help decrease hot flashes. Talk to your doctor to determine if medication is an option for you.
The following tips may also help: * Identify the triggers for your hot flashes. For many, hot flashes can be triggered by stress, a hot shower, caffeine or spicy foods. * Change your lifestyle habits to cope with your specific triggers. That may mean regular exercise, using relaxation techniques and changing your diet. * Dress in layers so that you can remove clothing if needed. * Keep ice water handy to help you cool off. * Avoid synthetic materials, especially at nighttime. Wear pajamas and use sheets made of cotton. * Take a cool shower before going to bed.
People with breast cancer who have undergone lymph node removal and/or radiation as part of their treatment are at risk for developing lymphedema, a condition in which the body’s lymphatic fluid is unable to circulate properly. The lymphatic fluid builds up in soft tissues (usually in an arm or a leg), causing painful swelling. In addition to swelling of the affected limb, the most common problems associated with lymphedema are pain, hardening of the skin and loss of mobility.
Here are some things you can do to ease the discomfort of lymphedema:
- Get help for your symptoms as soon as possible. Contact your health care team at the first sign of lymphedema symptoms. If left untreated, the swelling can get worse and may cause permanent damage.
- Consider undergoing manual lymph drainage (MLD). This is a type of massage that helps move the fluid from where it has settled. Afterward, the affected limb is wrapped in low-stretch bandages that are padded with foam or gauze.
- Learn exercises that can help prevent swelling due to fluid build-up. Your health care team can refer you to a program of special lymphedema exercises, taught and monitored by a physical therapist.
- Wear a compression sleeve. This can help drain the lymphatic fluid. It’s important to always wear a compression garment when flying, even on short flights.
- Be kind to your body. Carrying heavy packages, luggage or shoulder bags puts stress on your affected limb and could cause additional swelling and pain. Ask that any blood draws or insertion of intravenous (IV) lines be avoided on the affected arm.
Treatments for breast cancer can lead to vaginal dryness and a lowered sex drive. Use of a personal lubricant (such as Astroglide) and/or a moisturizer (such as Replens) can often help. If vaginal dryness persists, talk to your doctor about whether a prescription medicine is right for you. These medicines include hormone creams and suppositories (medicines inserted into the vagina). You may wish to ask for a referral to a health care professional who specializes in these issues.
Treatment-Specific Side Effects
The side effects specific to chemotherapy depend on the type and dose of drugs given and the length of time they are used. They can include the following:
- Hair loss. Depending on the treatment, hair loss may start anywhere from one to three weeks after the first chemotherapy session. If you choose to wear a wig, consider buying one before you lose much hair so you feel more prepared and so you can match your own hair color. You can have your wig professionally fitted and styled by a full-service wig salon. Look for a salon in your community that specializes in hair loss resulting from chemotherapy. Hair usually starts to grow back after the end of treatment. It may have a different texture or color, but these changes are usually temporary.
- Nerve damage. Some women being treated with chemotherapy experience nerve damage with symptoms that may include difficulty picking up objects or buttoning clothing, problems maintaining balance, difficulty walking and hearing loss. Peripheral neuropathy is a form of nerve damage that may cause numbness or tingling in the hands and feet. Often, nerve damage due to cancer treatments is temporary. If you are coping with this side effect, take extra care when handling hot, sharp or dangerous objects. You should also use handrails on stairs and in the tub or shower.
- Low white blood cell counts. Chemotherapy may lead to low white blood cell counts, a condition called neutropenia. White blood cells play a key role in fighting infection. Your doctor can prescribe medication designed to help increase white blood cell counts. If you develop a fever (a sign of infection), let your health care team know immediately so that you can get proper treatment.
- Mouth sores (mucositis) are also a side effect of chemotherapy. Your doctor may recommend treatments such as:
- Coating agents. These medications coat the entire lining of your mouth, forming a film to protect the sores and minimize pain.
- Topical painkillers. These are medications that can be applied directly to your mouth sores.
- Over-the-counter treatments. These include rinsing with baking soda or salt water or using “magic mouthwash,” a term given to a solution to treat mouth sores. Magic mouthwash usually contains at least three of these ingredients: an antibiotic, an antihistamine or local anesthetic, an antifungal, a corticosteroid and/or an antacid.
Chemotherapy can also cause changes in the way food and liquids taste, including an unpleasant metallic taste in the mouth. Many people find that switching to plastic utensils helps. It may also help to avoid eating or drinking anything that comes in a can and to use enamel-coated pots and pans for food preparation.
Changes to the skin are the most common side effects of radiation therapy. Those changes can include dryness, swelling, peeling, redness and blistering. If a reaction occurs, contact your health care team so the appropriate treatment can be prescribed. It’s especially important to contact your health care team if there is any open skin or painful area, as this could indicate an infection. Infections can be treated with an oral antibiotic or topical antibiotic cream.
Targeted Therapy and Hormone Therapy
Targeted therapy drugs and hormone therapy don’t have the same effect on the body as do chemotherapy drugs, but they can still cause side effects.
Side effects of certain targeted therapies can include diarrhea, liver problems (such as hepatitis and elevated liver enzymes), problems with blood clotting and wound healing and high blood pressure. Nerve damage, as outlined in the Chemotherapy Side Effects section, may also occur.
The side effects of hormone therapy are dependent on the specific type of therapy and include hot flashes (seen more with tamoxifen) and joint pain (seen more with aromatase inhibitors).
Immunotherapy travels through the bloodstream, helping to prompt what is called an “immune response.” Because immunotherapy can attack healthy cells as well as cancer cells, certain side effects may be experienced.
Atezolizumab is currently the only immunotherapy approved by the FDA for the treatment of breast cancer. Common side effects include digestive tract symptoms, fatigue, shortness of breath, elevated blood pressure and joint pain.
Q: What do “tumor grade” and “pathological stage” mean?
A: Tumor grade is a way of classifying tumors based on how closely the cancer cells resemble normal cells. This can be determined based on an examination of tumor tissue removed during a biopsy or at the time of surgery. Using a microscope, a pathologist rates the grade as 1, 2 or 3, which is an indication of whether the breast cancer is slow-growing, growing at a moderate pace or fast-growing.
Pathological stage describes the extent of the cancer within the body and is based on a pathologist’s study of the tumor tissue and any lymph nodes removed during surgery. The most widely used staging system, TNM, assesses the size of the tumor in the breast (T), the number and location of lymph nodes with cancer (N) and whether the cancer has spread beyond the breast and neighboring lymph nodes (M). Starting in 2018, the TNM system added the additional measures of tumor grade, estrogen receptor status, progesterone receptor status and HER2 status.
Q: My doctor suggested I see a genetic counselor. Why?
A: Genetic counseling can help people make informed decisions about genetic testing. In a genetic counseling session for breast cancer, the counselor will typically collect a detailed family and medical history and discuss genetic mutations, such as those in BRCA1 and BRCA2 genes, which can increase the chance of developing breast cancer.
Q: My breast cancer is being treated with chemotherapy. What can I do to preserve my fertility?
A: Chemotherapy may induce a temporary or permanent menopause among younger patients. For many of these individuals, preserving their fertility (the ability to have a child) plays a large part in their treatment decisions. There are steps that can be taken if you are concerned about your ability to have children after treatment:
Discuss treatment plans with members of your health care team. The discussion should include the coverage provided by your health insurance plan.
Consider consulting with a specialist in reproductive medicine, who can help weigh the benefits and risks of a specific treatment.
Ask about newer options for preserving fertility, such as oocyte cryopreservation, also known as egg freezing. In this process, the patient’s eggs are removed, frozen and stored for later use. Another option includes freezing fertilized eggs. You can discuss which option is best for you with your fertility specialist.
Fertility-preserving alternatives are most often used before the beginning of chemotherapy.
Q: Am I at higher risk of osteoporosis while being treated for breast cancer?
A: Some hormone therapies and chemotherapy can cause bone loss, which increases the risk of osteoporosis (a condition in which bones become weak and brittle). Talk with your health care team about how exercise and changes in your diet may help keep your bones healthy, and about the medications available for bone health:
Bisphosphonates such as zoledronic acid (Zometa and others) slow the process that causes bone to wear away and break down. These medications belong to a class of drugs called osteoclast inhibitors.
The RANK ligand inhibitor denosumab (Xgeva, Prolia) blocks a factor in bone development known as RANK ligand, which stimulates cells that break bone down. By blocking RANK ligand, these drugs increase bone density and strength. Like bisphosphonates, RANK ligand inhibitors are a type of osteoclast inhibitor.