Adjuvant drug therapy for stages I to III breast cancer

Adjuvant drug therapy for stages I to III breast cancer

Adjuvant drug therapy may be recommended, based on the tumor's size, spread to lymph
nodes, and other prognostic features. If it is, you may get chemotherapy, trastuzumab
(Herceptin), hormone therapy, or some combination of these.
Hormone therapy: Hormone therapy is not likely to be effective for women with
hormone receptor-negative tumors. Hormone therapy is frequently offered to all women
with hormone receptor–positive invasive breast cancer regardless of the size of the tumor
or the number of lymph nodes involved.
Women who are still having periods and have hormone receptor–positive tumors can be
treated with tamoxifen, which block the effects of estrogen being made by the ovaries.
Some doctors also give a luteinizing hormone-releasing hormone (LHRH) analog, which
makes the ovaries temporarily stop functioning. Another (permanent) option is surgical
removal of the ovaries (oophorectomy). Still, it is not clear that removing the ovaries or
stopping them from working helps tamoxifen work better for cancers that have been
removed completely. If the woman becomes post-menopausal within 5 years of starting
tamoxifen (either naturally or because her ovaries are removed), she may be switched
from tamoxifen to an aromatase inhibitor.
Sometimes a woman will stop having periods after chemotherapy or while on tamoxifen.
But this does not necessarily mean she is truly post-menopausal. The woman's doctor can
test for certain hormones to determine her menopausal status. This is important because
the aromatase inhibitors will only benefit post-menopausal women.
Women no longer having periods, or who are known to be in menopause at any age, and
who have hormone receptor–positive tumors will generally get adjuvant hormone therapy
either with an aromatase inhibitor (typically for 5 years), or with tamoxifen for 2 to 5
years followed by an aromatase inhibitor for 3 to 5 more years. For women who can't
take aromatase inhibitors, an alternative is tamoxifen for 5 years.
As mentioned before, there are still many unanswered questions about the best way to use
these drugs. For example, it's not clear if starting adjuvant therapy with one of these
drugs is better than giving tamoxifen for some length of time and then switching to an

aromatase inhibitor. Nor has the optimal length of treatment with aromatase inhibitors
been determined. Studies now under way should help answer these questions. You might
want to discuss these newer treatments with your doctor.
If chemo is to be given as well, hormone therapy is usually not started until after chemo
is completed.
Chemotherapy: Chemo is usually recommended for all women with an invasive breast
cancer whose tumor is hormone receptor-negative, and for women with hormone
receptor−positive tumors who might additionally benefit from having chemo along with
their hormone therapy, based on the stage and characteristics of their tumor.
Adjuvant chemo can decrease the risk of the cancer coming back, but it does not remove
the risk completely. Before deciding if it's right for you, it is important to understand the
chance of your cancer returning and how much adjuvant therapy will decrease that risk.
Your doctor should discuss what specific drug regimens are best for you based on your
cancer, its stage, your other health issues, and your preferences. The typical chemo
regimens are listed in the chemotherapy section. The length of these regimens usually
ranges from 3 to 6 months. In some cases, dose-dense chemo may be used (see the
Chemotherapy section for an explanation of dose-dense chemo).
Trastuzumab (Herceptin): Women who have HER2-positive cancers are usually given
trastuzumab along with chemo as part of their treatment.
A common chemo regimen is doxorubicin (Adriamycin) and cyclophosphamide together
for about 3 months (or 2 months if dose-dense chemo is used), followed by paclitaxel
(Taxol) and trastuzumab. The paclitaxel is given for about 3 months (2 months if dosedense
treatment is used), while the trastuzumab is given for a total of about 1 year.
A concern among doctors is that giving the trastuzumab so soon after doxorubicin may
lead to heart problems, so heart function is watched closely during treatment with tests
such as echocardiograms or MUGA scans.
To try to lessen the possible effects on the heart, doctors are also looking for effective
chemotherapy combinations that don't contain doxorubicin. One such regimen is called
TCH. It gives the chemotherapy drugs docetaxel (Taxotere) and carboplatin every 3
weeks along with weekly trastuzumab (Herceptin) for 6 cycles. This is followed by
trastuzumab every 3 weeks for a year.
Gene pattern tests: Some doctors may use newer gene pattern tests to help decide
whether to give adjuvant chemotherapy to women with certain stage I or II breast
cancers. Examples of such tests include Oncotype DX and MammaPrint, which are
described in more detail in the section "How is breast cancer diagnosed?" These tests are
done on a sample of your breast cancer tissue. They look at the function of several genes
within the cancer to help predict its risk of returning after treatment. The tests will not tell
your doctor which hormone therapy or chemotherapy is best for you. They can help your

doctor decide how useful adjuvant treatment may be for you. Large clinical trials are now
being done to see how helpful these tests may be in situations where doctors are often
uncertain, such as in women with small tumors and clear lymph nodes.
Online tools to help make decisions: To decide if adjuvant therapy is right for you, you
might want to visit the Mayo Clinic Web site at www.mayoclinic.com and type "adjuvant
therapy for breast cancer" into the search box. You will find a page that will help you to
understand the possible benefits and limits of adjuvant therapy.
Other online guides, such as www.adjuvantonline.com, are designed to be used by health
care professionals. This Web site provides information about your risk of the cancer
returning within the next 10 years and what benefits you might expect from hormone
therapy and/or chemotherapy. You may want to ask your doctor if he or she uses this site.
Stage IV
Stage IV cancers have spread beyond the breast and lymph nodes to other parts of the
body. Breast cancer most commonly spreads to the bones, liver, and lung. As the cancer
progresses, it may spread to the brain, but it can affect any organ, even the eye.
Although surgery and/or radiation may be useful in some situations (see below), systemic
therapy is the main treatment. Depending on many factors, this may consist of hormone
therapy, chemotherapy, targeted therapies, or some combination of these treatments.
Treatment can shrink tumors, improve symptoms, and help patients live longer, but it
isn’t able to cure these cancers (make the cancer go away and stay away).
Trastuzumab may help women with HER2-positive cancers live longer if it is given with
the first chemo for stage IV disease. Giving pertuzumab with chemo and trastuzumab
may help even more. Trastuzumab can also be given with the hormone therapy drug
letrozole. It is not clear how long treatment with trastuzumab or pertuzumab should
continue.
All of the systemic therapies given for breast cancer—hormone therapy, chemo, and
targeted therapies—have possible side effects, which were described in previous sections.
Your doctor will explain to you the benefits and risks of these treatments before
prescribing them.
Radiation therapy and/or surgery may also be used in certain situations, such as:
· When the breast tumor is causing an open wound in the breast (or chest)
· To treat a small number of metastases in a certain area
· To prevent bone fractures
· When an area of cancer spread is pressing on the spinal cord

· To treat a blockage in the liver
· To provide relief of pain or other symptoms
· When the cancer has spread to the brain
If your doctor recommends such local treatments, it is important that you understand their
goal—whether it is to try to cure the cancer or to prevent or treat symptoms.
In some cases, regional chemo (where drugs are delivered directly into a certain area,
such as the fluid around the brain or into the liver) may be useful as well.
Treatment to relieve symptoms depends on where the cancer has spread. For example,
pain from bone metastases may be treated with external beam radiation therapy and/or
bisphosphonates such as pamidronate (Aredia) or zoledronic acid (Zometa). Most doctors
recommend bisphosphonates or denosumab (Xgeva), along with calcium and vitamin D,
for all patients whose breast cancer has spread to their bones. (For more information
about treatment of bone metastases, see our document, Bone Metastasis.)