Can I Skip Chemotherapy for My Breast Cancer? Guidelines

Not everyone who is diagnosed with breast cancer will require chemotherapy. While chemotherapy is required for many people with invasive breast cancer, some people can skip chemotherapy entirely.

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Either due to concerns about chemotherapy or other reasons, you may be wondering if you might be able to skip chemotherapy after a breast cancer diagnosis.

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You can skip chemotherapy if your cancer has a low risk of coming back in other parts of the body. In addition, if you have other serious medical problems, chemotherapy may cause more harm than good. In advanced cancer, we generally use hormonal therapy before starting chemotherapy.

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This post will give you an overview about whether you might be able to skip chemotherapy. We will also give you a description of the types of breast cancer that generally do not have chemotherapy as part of the treatment plan.

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First of all, what is the purpose of chemotherapy?

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Chemotherapy is given to reduce the risk of cancer coming back in other parts of the body years or months after the cancer has been removed. Chemotherapy goes through your whole system. You may hear the word “systemic” because chemotherapy goes through your whole system, your whole body.

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Chemotherapy can be given before or after surgery for breast cancer. Chemotherapy is given into a vein. The medicine can be given either in small syringe, a small iv bag, or a larger iv bag. Chemotherapy drugs reach most parts of the body through the bloodstream and can kill cancer cells that may have spread to other parts of the body, such as liver, lung, or bone.

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Chemotherapy is never given to people who have ductal carcinoma in situ (DCIS, Stage 0).

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How can I tell if I am less likely to get a benefit of chemotherapy?

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In general, chemotherapy is not necessary if the risk of the cancer coming back is low. This is because adding chemotherapy does not give you any benefit.

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When determining whether or not someone has a high risk of the cancer coming back, we look at several things:

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• the tumor size

• whether or not the lymph nodes have cancer in them

• the biologic features of the tumor

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(including the tumor grade, hormone receptors, and whether or not the tumor is HER2-positive)

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If your cancer falls into the following groups, chemotherapy will probably not be part of your treatment plan.

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• Small tumor– less than one-half (0.5) of a centimeter (the size of a green pea) and the lymph nodes (glands) do not have cancer in them or there is only a tiny amount of cancer

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If you have negative lymph nodes and a tumor that is larger than one-half of a centimeter, you may be able to skip chemotherapy if the following features apply to you…

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• Low grade tumor (grade refers to how similar the cells are to normal breast tissue)

• Positive hormone receptors (refers to the presence of estrogen and/or progesterone receptors)‍

• Negative for overexpression or overamplification of the HER2 protein (refers to not having the HER-2 protein or extra copies of the gene)

• A low recurrence score on a multigene tumor assay (refers to the results of a gene test done on the tumor specimen itself)

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If you have positive lymph nodes but the number is low nodes (1, 2, or 3) and the tumor has all of the above tumor features, you may also be able to skip chemotherapy.

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There are two of subtypes of breast cancer that have a low risk of coming back in other parts of the body. If you have negative lymph nodes and one of the tumor types below, you can skip chemotherapy.

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• Mucinous breast cancer (also called colloid carcinoma)
• Tubular breast cancer

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Why would someone want to avoid chemotherapy?

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If the short-term and long-term side effects are greater than the expected improvements in recurrence, the chance you will benefit from chemotherapy is low.

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Side effects of chemotherapy are different for different combinations of drugs. In addition, everyone reacts differently to chemotherapy.

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Some of the side effects of chemotherapy include fatigue, temporary hair loss, nail changes, nausea, diarrhea and constipation.

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Some people gain weight on chemotherapy because they move less.

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Most of these side effects will improve when chemotherapy is over. In addition, many of the side effects can be reduced with medicine that is given along with the chemotherapy.

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The long-term side effects of chemotherapy include

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1. Changes in ovarian function, which can lead to

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• changes in menstrual periods for younger people

• early menopause

• infertility, may occur and may be permanent

• increased bone loss due to menopause

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2. Decrease in the “pump” function of the heart can occur with some chemotherapy

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• The risk of heart problems is higher if you already have heart failure, severe diabetes, or uncontrolled hypertension.

• Heart problems are usually reversible and can usually be treated.

• If you have heart problems, your doctors will use chemotherapy that is less likely to cause further heart problems.

• Your heart function will be checked during chemotherapy.

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3. Nerve problems can happen with some chemotherapy. This can lead to:

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• Numbness, pain, burning or tingling sensations, increased sensitivity to temperature. Symptoms usually show up in the fingers and toes.

• Symptoms usually go away after chemotherapy, but some people have symptoms have long-term effects on their ability to feel in their fingers and toes.

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4. Long-term fatigue in some people after chemotherapy.

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• In about 1 in 20 people, the fatigue can last a long time.

• There are things you can do to improve your energy levels.

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What if I already have serious medical problems?

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If you have serious medical problems, the benefit of chemotherapy will be lower. We generally give chemotherapy only if someone has a long life expectancy. If you are living with other serious medical problems, the chance is higher that your other problems will be a greater threat to your survival than your breast cancer.

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If you have serious medical problems but have a longer life expectancy (10 or more years), chemotherapy is more likely to help you.

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You can ask for help from your medical team in estimating your life expectancy when making decisions about whether or not you get chemotherapy.

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What if I don’t want chemotherapy?

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You do not have to have chemotherapy. Your medical team will explain the benefits of chemotherapy to you, but this decision is yours.

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Your medical team should and will make sure that you understand all of the following:

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• The purpose of chemotherapy

• The risk of the cancer coming back without chemotherapy

• The risk of the cancer not coming back with chemotherapy

• What it means to you if the cancer comes back

• Surgery and radiation therapy do not decrease the risk of the cancer coming back in other parts of your body

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The use of chemotherapy overall and the specific drugs used to treat breast cancer have been studied in thousands of people. The research studies include short-term and long-term side effects.

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Before oncologists start using a particular combination of drugs, we generally have information about the risks and benefits of that particular combination.

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There is no evidence that herbal supplements, vitamins, shark cartilage, mistletoe, or other approaches can cure cancer.

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If you are on a clinical trial, your medical team will explain all the risks and benefits of participating in a clinical trial.

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Do I need chemotherapy if I have advanced breast cancer?

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If you have advanced cancer, the cancer has shown up in other parts of the body. The cancer may be seen in organs such as lung, liver, or bones.

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People with advanced cancer may eventually need chemotherapy. However, depending on the tumor characteristics (details below), your doctor will recommend other types of treatment first. Eventually, chemotherapy is likely to be part of your treatment because these other treatments will stop working your doctor will eventually advise chemotherapy. You do not have to have chemotherapy if you would like to focus on managing your symptoms and avoiding additional treatment.

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What are some of the other therapies for advanced breast cancer instead of chemotherapy?

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Other therapies that can be used if you have advanced cancer include

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• Hormonal therapy (for people whose tumor is hormone receptor-positive)

• Suppression or removal of the ovaries in people who have not been on hormonal therapy for a year or more

• Targeted therapy only (for people whose tumor is HER2-positive)

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Summary

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In summary, chemotherapy is not always needed in people with early stage or advanced breast cancer. Chemotherapy is never used in people with ductal carcinoma in situ (DCIS, Stage 0).

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Decisions about chemotherapy in your case will be made with you and your medical oncologist. Make sure you understand why you are getting chemotherapy, what to expect, and how you can prevent and reduce side effects.

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If your cancer has a low risk of coming back in other parts of your body, chemotherapy will not be part of your treatment plan. Tumor size, whether or not the lymph nodes have cancer, tumor biology (“personality”), your overall health, and your preferences will play a role in decisions about your chemotherapy.

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If you have serious medical problems, the benefits of chemotherapy may not be as great as the risks.

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If you are living with advanced breast cancer, you may have other options for treatment before chemotherapy will be necessary.

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References

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1. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer. National Comprehensive Cancer Network. Available at http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Version 2.2019-July 2, 2019. Last accessed on: September 12, 2020.

2. Chemotherapy for Breast Cancer. American Cancer Society; Sept 18, 2019. Url: https://www.cancer.org/cancer/breast-cancer/treatment/chemotherapy-for-breast-cancer.html Last accessed on: September 12, 2020.