Once I had been diagnosed with Breast Cancer, I was referred to my surgeon, Dr Elisabeth Rippy. Dr Rippy was recommended by my own GP and the GP at the breast clinic; good enough for me.
Upon the recommendation of Dr Rippy I am having what they refer to as Neoadjuvant chemotherapy. This is where I have chemotherapy first before any other treatment. As I have small breasts, Dr Rippy wants to save the breast as much as possible. This will then be followed by surgery, then radiation.
Chemotherapy is a treatment which uses drugs to destroy cancer cells. It is sometimes used after breast cancer surgery to kill any undetectable cancer cells that may be left in the breast or lymph nodes.
Chemotherapy can lower the risk of breast cancer coming back.
Chemotherapy can also be used before surgery. This is called neoadjuvant chemotherapy.
Will I need chemotherapy?
Many women with breast cancer are referred to a medical oncologist to discuss whether or not chemotherapy is recommended for them. Chemotherapy is offered to some women as an additional treatment to surgery, radiotherapy, and/or hormonal therapy.
A molecular test is a test that can predict the likelihood of an individual cancer recurring (coming back) and provide information to help you decide whether or not you may benefit from chemotherapy or some other breast cancer treatments.
Your doctor may talk to you about molecular tests currently available, including:
- Oncotype DX Breast Cancer Assay
These tests are not covered by Medicare and can be quite expensive – up to several thousand dollars. For further information about molecular testing, visit the Breast cancer pathology page or talk to your surgeon or medical oncologist.
How does chemotherapy work?
Chemotherapy works by attacking fast-growing cells in your body, including cancer cells. There are many different types of chemotherapy; your medical oncologist will talk to you about what’s most suitable for you. Sometimes more than one type of treatment may be effective for you, and you may be asked to decide which one to have. Your medical oncologist can tell you about the pros and cons of each.
Some questions you might like to ask include:
- What are the possible side effects of each treatment?
- How long is the course of each treatment?
- How will the treatment fit in with my lifestyle and personal circumstances?
Some chemotherapy drugs are given in tablet form, however, most are administered intravenously (by needle into a vein in the arm or hand). As a result, it is useful to drink plenty of fluids, relax and keep your hands and arms warm, as this can help the nurse or doctor find your veins.
What are the side effects?
Chemotherapy is sometimes referred to as a systemic treatment, because it affects all parts of your body. Unfortunately, it can attack fast-growing healthy cells, such as hair follicles, as well as cancer cells. This causes unwanted side effects such as fatigue, nausea and hair loss. Your medical oncologist or oncology nurse can give you information on ways to manage these side effects.
If side effects are affecting your daily life, it’s important to discuss them with a member of your medical team. In some instances, your oncologist may be able to change your chemotherapy drug to one that has fewer side effects.
Chemotherapy drugs all work differently and have different side effects. Not all women will suffer side effects from chemotherapy. If you don’t experience side effects, it does not mean that the drugs aren’t working.
Hair loss (alopecia) can be one of the most upsetting side effects of chemotherapy. The Hair loss page contains useful information and strategies on how to deal with hair loss.
Nausea and vomiting are common side effects of chemotherapy. You may be given anti-nausea medication before your chemotherapy to take home with you, in case you need it later. Let your doctor know if you have nausea and/or vomiting that lasts for more than 24 hours. It’s easy to become dehydrated quickly, and your doctor can help with this.
During chemotherapy, women sometimes develop mouth ulcers and changes in taste. Rinsing your mouth regularly with bicarbonate of soda can help to prevent ulcers, even before you begin chemotherapy. If ulcers do develop, you may find it gentler to use a child’s toothbrush to brush your teeth. Eating soft mints can help get rid of the metallic taste that you may experience. If you have a sore mouth and are not eating properly, chilled drinks such as smoothies from the blender can be good.
Chemotherapy can reduce your oestrogen levels and cause periods to stop, either temporarily or altogether. This is called early menopause. You may experience some of the symptoms of menopause, such as hot flushes and night sweats. BCNA’s Menopause and breast cancer booklet provides practical tips to help manage the symptoms of menopause. You can download or order a copy from our Booklets and fact sheets page.
As chemotherapy reduces the level of oestrogen in your body, it can also reduce your bone density and increase your risk of bone fractures. The Bone health page of this website provides more information on how to improve bone health. You can also download BCNA’s Bone health fact sheet from the Booklets and fact sheets page.
Nail changes are a common side effect of some chemotherapy treatments. The Nail changes page provides more information on the changes that may occur to your nails, including what you can do manage nail changes.
Fatigue is very common during chemotherapy. Many women describe it as being quite different from normal tiredness. The Fatigue page contains more information on how to manage fatigue. You can also find more information in our section on physical wellbeing.
Some women who have chemotherapy say that they experience a side effect known as ‘chemo brain’ or ‘chemo fog’. It is best described as feeling vague. Some women say they have trouble remembering things and find they aren’t as organised as usual. The Chemo brain page includes suggestions on how to manage the effects of chemo brain.
Loss of fertility
Chemotherapy may reduce a woman’s fertility and reduce her chance of having children in the future. There are a number of factors that contribute to this issue, including a woman’s age, and the type of treatment she has and how it affects her ovaries. There are a number of methods for preserving fertility. The Breast cancer in young women page has more information on this issue.
Chemotherapy is most commonly used after breast cancer surgery to kill any cancer cells that may be left in the breast or lymph nodes or in other parts of your body. When it is used after surgery, it is referred to as adjuvant chemotherapy.
Sometimes doctors suggest chemotherapy and other treatments be given before breast cancer surgery. This is called neoadjuvant therapy.
There are a number of reasons why neoadjuvant chemotherapy may be offered to you.
What is neoadjuvant chemotherapy?
With neoadjuvant chemotherapy, you are likely to be given the same chemotherapy drugs that you would be given if you have chemotherapy after your surgery. The aim of treatment is to shrink the tumour in the breast, along with any other breast cancer cells that may be present elsewhere in the body, by killing those cancers cells.
There are some benefits in having neoadjuvant chemotherapy, but it is not for everyone. You may want to consider your options carefully.
Why might neoadjuvant chemotherapy be recommended for me?
Neoadjuvant chemotherapy may be recommended:
- To reduce the size of your breast cancer (tumour) if it is too big to be removed in an operation
- If you have inflammatory breast cancer
- To reduce the size of the tumour so that you can have breast conserving surgery (lumpectomy) instead of mastectomy
- To reduce the size of the tumour so that a smaller amount of tissue can be removed – this may give you a better cosmetic outcome
- To give you time to have genetic testing if you have a strong family history of breast cancer – you may decide to have a different type of surgery if you are found to have an inherited breast cancer gene mutation
- To delay surgery if you are pregnant so that you can deliver your baby as near to full term as possible (certain breast cancer chemotherapy drugs have been found to be safe in pregnancy)
- To give you time to consider your surgical options, including breast reconstruction
I was prescribed FEC-D by my Oncologist and the following are the details.
Each cycle was repeated every 21 days and I was given 3 cycles of each.
FEC is the first part of the regimen.
How is it given:
Given by drip into a vein
How long does it take:
About 2 hours long
D is the second part of the FEC-D regime.
How is it given:
Given by drip into a vein
How long does it take:
About 1.5 hours long
Breast conserving surgery, also known as a wide local excision or lumpectomy, involves the removal of the area of DCIS along with a small amount of healthy surrounding tissue called the surgical margin.
Breast conserving surgery may be recommended if the:
- Area of DCIS is small and can be completely removed with clear margins of healthy tissue. DCIS is only in one area of the breast.
The surgeon will leave as much breast tissue as possible behind so that the breast can stay as close as possible to normal size. Occasionally, the breast may need to be reshaped or nearby body tissue used to replace the tissue removed from the breast using techniques of oncoplastic surgery.
Sometimes after breast conserving surgery, further surgery may be necessary if:
- There are abnormal cells in the edge of breast tissue removed (surgical margin).
- The amount or grade of DCIS found was more than suspected and a bigger operation is needed to remove all of the abnormal area within the breast.
- An unsuspected invasive breast cancer is identified in the tissue removed during surgery.
A usual part of breast cancer surgery is to remove the lymph nodes from the armpit (axilla) to see if there is any evidence that the cancer has spread from the breast to the lymph nodes and therefore, potentially, to other parts of the body. This information, along with other factors such as the size and grade of the tumour, helps the doctors determine the stage of the breast cancer and the most appropriate treatment.
One potential side effect of removing the lymph nodes from the armpit is a life-long risk of developing lymphoedema (swelling) in that arm. Alternative techniques, with fewer side-effects are of interest to researchers. One of these, sentinel node biopsy, has been the subject of recent national and international research.
Sentinel node biopsy is a surgical technique in which the first lymph node (or nodes) that cancer may spread to is removed. If the sentinel node does not have any cancer cells present, it is thought that the other nodes may also be clear of cancer. In this case removal of further nodes is not performed and consequently the risk of lymphoedema is significantly reduced and the recovery time is improved. If the sentinel node contains cancer, then the axillary lymph nodes are removed.
Many Australian women have participated in clinical trials such as the Royal Australasian College of Surgeons (RACS) Sentinel Node versus Axillary Clearance (SNAC) trial. Results from these trials suggest that sentinel node biopsy is safe for women with small, early breast cancers, although as yet there are no long term results from the research. The ability of this procedure to detect positive lymph nodes is very good. However, in some women, the sentinel node is clear, but cancer cells are actually present in other nodes.
- Women should be fully informed, prior to choosing the type of surgery they wish to undergo, about the risks and benefits associated with all of the treatment options available to them.
- It is important that women discuss the potential risks for them as an individual with their surgeon before making a decision to undergo any surgical technique.
- If women choose to undergo sentinel node biopsy as a surgical procedure outside of a clinical trial, then they should satisfy themselves that their surgeon is competent to perform this surgical procedure. This means that the surgeon has complied with the position of the Breast Section of RACS regarding auditing their surgical cases against level 2 dissection using the SNAC trial protocol as a guide.
- If women with large or multi-focal tumours choose to participate in clinical trials of sentinel node biopsy it is essential that they be provided with full information about any possible increase in their risk of developing a breast cancer recurrence that might result from them undergoing this procedure as an alternative to axillary clearance.
Radiotherapy, sometimes referred to as radiation therapy, involves the use of X-rays to destroy abnormal cells that may be left in the breast after surgery. Radiotherapy is a localised treatment, which means it only treats the area of the body it is aimed at.
If your treating team is considering radiotherapy, you will be referred to a radiation oncologist who will talk to you about the plan for your treatment, including timing, how it will be delivered and the side effects that you are likely to experience.
Radiotherapy is usually recommended after breast conserving surgery. Radiotherapy is not usually needed after mastectomy.
Radiotherapy aims to:
- lower the risk of DCIS coming back.
- reduce the risk of invasive breast cancer by treating any abnormal cells that may remain in the breast after surgery.
- Having no radiotherapy after breast conserving surgery may be recommended if the benefit of radiotherapy is considered to be minimal and your risk of recurrence is low.
The benefit of radiotherapy is low if:
- your DCIS is small (just a few millimetres) and low grade
- the DCIS is removed with enough healthy tissue around the DCIS (clear margins)
- you are at an older age (over 70) at diagnosis.
However, the definition of ‘low risk’ is not always clear. If you decide on surgery only, then it is important that you receive close follow-up and monitoring. This may include regular breast examinations and imaging tests such as mammograms, ultrasound or, in special circumstances, an MRI. The decision not to have radiotherapy must be considered carefully with your treating team. A second opinion can also be helpful.
Radiotherapy for DCIS is usually given every week day for five weeks (usually not on weekends). The addition of a ‘boost’ is being studied in clinical trials but long-term outcome results of these trials are still awaited. External radiation is usually given to the entire breast and can reduce the risk of developing DCIS again or of developing invasive breast cancer by at least half.