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Chemotherapy is often used in metastatic breast cancer.
Your doctor will recommend specific chemotherapy medication for you. Most of the time, one chemotherapy drug is used at a time. In metastatic breast cancer, we continue each type of chemotherapy until it stops working or until you want to stop, usually because of side effects. At that point, you will switch to a different treatment.
This article focuses on chemotherapy for metastatic breast cancer.
What is metastatic breast cancer?
Metastatic breast cancer can also be called advanced breast cancer or Stage IV breast cancer.
Metastatic breast cancer occurs when the cancer leaves the breast tissue and nearby lymph nodes to spread to other parts of the body, such as the lungs, bones, liver, or brain. The original tumor location (the breast in this case) is called the “primary site.” When cancer has spread to other parts of the body, this is called “metastatic.” The new tumor location is called the “metastatic site” or “metastatic tumor.”
Breast cancer can spread to other parts of the body through the bloodstream or through the lymph channels. Once cancer gets to this new area, the cancer cells start to grow in the new sites.
Even though the cancer is now growing in a new part of the body, it is still breast cancer.
When cancer spreads to another part of the body, the goal of treatment is to control the disease. Metastatic breast cancer is generally not considered curable although some people can live for many years. Treatment is used to stop the cancer growth, slow the cancer growth, or to decrease symptoms caused by the cancer.
Improving your quality of life and your ability to live the life you want is the most important goal of chemotherapy is right for you.
What is chemotherapy?
Chemotherapy refers to drugs that treat cancer by killing the cells or stopping them from dividing. Chemotherapy works by specifically targeting rapidly dividing cells. It does this by focusing on specific parts of the cell that make the cells split into two. More about chemotherapy drugs and the molecules they target are explained in the “Chemotherapy Options in Metastatic Breast Cancer” section below.
Chemotherapy can be given as an infusion into the vein or by mouth in pill form.
A list of chemotherapy options for metastatic breast cancer are outlined in detail in the “Chemotherapy Regimens” section below.
How do we decide which chemotherapy is right for you?
We look at several factors when deciding which chemotherapy to use.
What chemotherapy have you already had? If this is the first treatment for metastatic breast cancer, we have more options than if this is one of many treatments you have had. If you have other treatments, we will pick chemotherapy that works in a different way.
What side effects are important for you to avoid? If you have side effects from treatments you have had in the past, we will pick chemotherapy that is less likely to make that side effect worse. For example, if you have numbness in your fingers or toes from treatment you have had in the past, we will avoid chemotherapy that will cause the numbness and tingling to get worse.
Do you have other medical problems? We try not to give a chemotherapy that will make your other medical conditions worse. For example, if you have problems with your heart, we will try to avoid chemotherapy that will make your heart condition worse.
Does your tumor have the HER2 protein? HER2 stands for human epidermal growth factor receptor-2. If cancer cells have larger-than-normal amounts of HER2 receptors, they are classified as HER2-positive, or HER2(+). If they do not have larger-than-normal amounts of HER2 receptors, then they are classified as HER2-negative, or HER2(-). About 1 in 5 people have a tumor that is HER2-positive.
If the breast cancer is HER2-positive, chemotherapy is used in combination with drugs that specifically target HER2. In other words, you will receive both chemotherapy and HER2-targeted therapy.
Does your tumor have other tumor markers? In addition to HER2, there are other tumor features that can be treated with targeted therapy. Further discussion of these targeted therapies is not the focus of this article, but it is important to know that there are more and more options for targeted therapy.
How hard is it for you to take time and travel to your treatment appointments? One thing we can consider when choosing a chemotherapy plan is how often the treatment is given and how long each treatment takes. For example, if you have to drive 4 hours to get treatment, we will pick chemotherapy that can be given once a month. If you have a more flexible schedule and live closer, a treatment that is given for a shorter time period once a week may be better for you.
What else? We balance all of the above and more. Make sure that you understand your treatment options and how decisions are made about your treatment.
Chemotherapy Options in Metastatic Breast Cancer
Below are the chemotherapy options available for the treatment of metastatic breast cancer. Each section walks through possible side effects the medication may cause. However, you can still have side effects that are not listed below.
Doxorubicin
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Brand name: Adriamycin
Doxorubicin is a type of drug called an anthracycline. Anthracyclines kill cancer in several ways. One way is by creating substances within the cells to kill them. Anthracyclines can prevent cancer cells from dividing as well.
Doxorubicin is given as an infusion into the vein. It usually takes about 30 minutes. Doxorubicin is a red solution and can change the color of your sweat, tears, and urine to a reddish color. Other side effects are nausea and vomiting, diarrhea, mouth irritation or mouth sores.
Liposomal doxorubicin
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Brand name: Doxil
Liposomal doxorubicin is part of the group of drugs known as anthracyclines. One way anthracyclines work is by creating substances in the cancer cells to kill them. They also prevent cancer cells from dividing.
Liposomal doxorubicin is given as an infusion into the vein. It takes about 60 minutes to complete the infusion. This medication is a reddish-orange color, so it may change the color of your sweat, tears, urine, and other body fluids to a reddish tint. Liposomal doxorubicin can cause throat irritation or cause your body to feel tired or weak.
Compared to doxorubicin discussed above, lisposomal doxorubicin is less likely to cause problems in the vein. It is also less likely to cause nausea and vomiting, but it still could cause these side effects for you. It can also cause stomach pain, stomach upset, constipation, or diarrhea.
Epirubicin
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Brand name: Ellence
Epirubicin belongs to the group of drugs called anthracyclines. Anthracyclines fight cancer in a few different ways. One way is creating a substance in the cancer cells that ends up killing them. Another way is by preventing the cancer cells from dividing.
Epirubicin is given as an infusion into your vein. This will take less than 30 minutes to complete. The infusion may cause blistering when the drug is given. If this happens, your doctor will apply a dry cold compress and give you medication to treat it.
Epirubicin is reddish in color, so your urine and other body fluids may have a red or orange color. This drug may cause you to feel like you have less energy. It can cause nausea, vomiting, and other stomach problems. You may also experience hot flashes or mouth sores.
Paclitaxel
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Brand name: Taxol
Paclitaxel is part of the group of medications called taxanes. Drugs in this group treat cancer by stopping the function of a molecule called microtubules, which eventually stops cell growth.
Paclitaxel is given as an infusion into your vein. This infusion takes 1 to 3 hours, depending on the dose.
A few side effects of paclitaxel are overall weakness or lack of energy, nausea, diarrhea, numbness of the fingers and toes, and changes in your nails.
Paclitaxel can also cause a cluster of reactions called hypersensitivity reactions. These are a group of symptoms that look like allergy symptoms, such as fever, redness, itching, and high or low blood pressure. Your doctor may give you a short course of medication before you start paclitaxel to prevent hypersensitivity reactions.
Albumin-bound paclitaxel
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(also called protein-bound paclitaxel)
Brand name: Abraxane
Albumin-bound paclitaxel belongs to a group of medications called taxanes. In cancer, taxanes stop the function of this molecule called microtubules. Doing this, eventually stops the cancer from growing and dividing.
Albumin-bound paclitaxel is given as an infusion into the vein, which takes about 30 minutes.
This medication causes stomach/digestion issues like nausea, diarrhea, constipation, and reduced appetite. Fatigue is common with most chemotherapy.
Docetaxel
doe se TAKS el
Brand name: Taxotere
Docetaxel is a type of drug called a taxane. Taxanes kill cancer cells by stopping a molecule, called a microtubule, from working. This eventually prevents the cancer from growing and dividing.
This medication is given as a 1-hour infusion into the vein. It can cause a group of symptoms called hypersensitivity reactions. These are symptoms that mimic allergy symptoms, so they may cause redness, fever, itching, and high or low blood pressure. Before you take docetaxel, your doctor may give you a shot course of medications to prevent these hypersensitivity reactions.
This medication can cause mouth sores, nausea, and diarrhea. Docetaxel may also cause deep muscle pain, overall weakness, fever, or nail changes.
Fluorouracil
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Also known as: 5-fluorouracil or 5-FU
Brand name: Adrucil
Fluorouracil belongs to a group of medications called anti-metabolites. Anti-metabolites work by getting in the way of cancer cells making DNA. This means that the cancer cell will not able to grow and divide.
For metastatic breast cancer, fluorouracil is given as an infusion into the vein. Some side effects include reduced appetite, diarrhea, dry skin, and nail changes. Nausea is uncommon.
Capecitabine
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Brand name: Xeloda
Capecitabine is a kind of anti-metabolite drug. This means that it treats cancer by stopping the cancer from making DNA. This prevents the cancer from growing and dividing.
This medication is given as a pill. This is basically the tablet form of fluorouracil (discussed above). Capecitabine is given as a tablet twice a day for 2 weeks out of a 3-week cycle. Many people need to have the dose lowered. Other options are to give the medicine for one week followed by a week off.
Capecitabine can cause tingling, prickling, numbness, or burning on your hands and feet. It may also cause red or peeling skin that looks like sunburn or blisters on the bottom of your hands and feet. This drug can cause stomach issues like diarrhea, nausea, constipation, stomach pain, and reduced appetite. Capecitabine may also cause lack of energy, mouth sores, eye irritation, fever, or make you feel overall tiredness.
Gemcitabine
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Brand name: Infugem
Gemcitabine is part of a group of medications called anti-metabolites. Drugs in this class kill cancer cells by preventing them from making DNA. When the cancer cell cannot make DNA, then it is not able to grow or divide into more cancer cells.
Gemcitabine is given as an infusion into the vein that takes about 30 minutes to complete.
This drug can cause skin rashes, diarrhea, drowsiness, fever, shortness of breath, or mouth sores. It can also cause flu-like symptoms, such as fever, chills, muscle aches, or an overall “unwell” feeling. Rarely, people can get swelling of the feet or hands. Nausea is uncommon.
Methotrexate
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Methotrexate belongs to a group of folate anti-metabolites. Folate anti-metabolites prevent cancer cells from making DNA by binding to certain compounds in the cancer cell, eventually stopping the cancer cell from growing and dividing. When folate anti-metabolites binds to these compounds, it also stops the formation of folates. This is why it’s called a folate anti-metabolite.
For metastatic breast cancer, methotrexate is given as an infusion into the vein.
Methotrexate may cause tummy issues such as nausea, vomiting, stomach pain, and reduced appetite.
Vinorelbine
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Brand name: Navelbine
Vinorelbine is part of a group of drugs called vinca alkaloids. This drug group kills cancer cells by blocking the compound called microtubules. Blocking this compound stops the cancer from completing its growth.
Vinorelbine is given as an infusion into the vein. The infusion can cause pain in the vein.
Vinorelbine may cause constipation, diarrhea, and decreased appetite. It may cause pain in your joints, muscle, or nerves. Vinorelbine may cause you to feel physically weak like you have lost your strength. It may cause tingling or numbness in your arms or legs. Nausea is uncommon.
Eribulin
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Brand name: Halaven
Eribulin belongs to a group of drugs called microtubule inhibitors. This group of drugs kills cancer cells by preventing the cells from completing their growth cycle.
Epirublin is given as an infusion into the vein over a few minutes.
This medication can cause tummy issues such as nausea, vomiting, diarrhea, constipation, stomach pain, reduced appetite, and weight loss. Epirublin may also cause headaches or pain in your nerves, muscle, back, bones, arms, and legs. This drug may cause you to feel more tired, and can cause mouth sores, fever, coughing, and shortness of breath.
Ixabepilone
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Brand name: Ixempra
Ixabepilone is in a group of drugs called microtubule inhibitors. These drugs kill cancer cells by stopping a compound called a microtubule. This eventually causes the cancer cell to stop growing.
Ixabepilone is given as an infusion into the vein for about 3 hours. This medication can cause hypersensitivity reactions, which is a group of symptoms that look like allergies. These symptoms are fever, redness, itching, low blood pressure, and others. You will receive a short course of medications before getting ixabepilone to stop the hypersensitivity reactions from happening.
Ixabepilone may cause pain in your nerves, muscles, joints. This drug can cause nausea, vomiting, diarrhea, constipation, stomach pain, or weight loss. Mouth sores or an overall feeling of weakness may also be experienced.
Carboplatin
KAR boe pla tin
Brand name: Paraplatin
Carboplatin belongs to a group of drugs called platinum-based drugs. Platinum-based drugs kill cancer cells by inserting itself into the cancer cells, which causes them to die.
Carboplatin is given as an infusion into the vein.
This medication may cause pain, weakness, tingling of the toes and fingers, nausea, and stomach pain.
Cisplatin
SIS pla tin
Cisplatin is in a group of drugs called platinum-based drugs. These drugs kill cancer cells by inserting themselves into the cancer cells, eventually causing them to die.
Cisplatin is given as an infusion into the vein. It is important to stay hydrated while on this medication. Your doctor may give you something to help you stay hydrated before starting this medication. Cisplatin may cause blistering when it is infused. If this happens, you will receive a medication to treat it.
Cisplatin has a high chance of causing nausea and vomiting. You may receive medications before you start cisplatin to prevent these stomach issues from happening.
This medication may cause pain, weakness, tingling of the toes and fingers, nausea, vomiting, stomach pain, and decreased hearing.
Cyclophosphamide
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Cyclophosphamide is part of a group of drugs called alkylating agents. These drugs kill cancer cells by inserting a compound into the cancer cell, which causes it to die.
For metastatic breast cancer, cyclophosphamide is usually given as an infusion into a vein. Less commonly, it is given as a pill.
Cyclophosphamide may cause nausea, vomiting, and diarrhea. It may also cause you to feel less hungry.
Targeted Drugs Used With Chemotherapy
When you are given a treatment plan for metastatic breast cancer, your plan may have other drugs combined with chemotherapy. These other drugs are called targeted drugs. In metastatic breast cancer, targeted drugs are sometimes added to chemotherapy to help treat the cancer better.
Targeted drugs target specific molecules in cancer cells. Each drug has a different molecule that they target.
Chemotherapy Specifics
Below is a list of example chemotherapy drugs, including combinations, that are used in metastatic breast cancer. The examples in the table that have “(+ targeted therapy)” added to it may be combined with a targeted therapy discussed in the section above. The table below tells you if the regimen is used in HER2-positive, HER2-negative, or triple negative breast cancer (TNBC).
The table below also tells you how the medications are given and the schedule of when the drugs are taken. There is also a comments section for more information. In metastatic breast cancer, chemotherapy regimens are given until the medications are no longer working or until the side effects can no longer be managed.
Chemotherapy Side Effects
Common chemotherapy side effects include fatigue, constipation or diarrhea, nausea, and low white blood cells counts. We know how to manage most of these side effects.
If you have any side effects from your cancer or medication, let your medical team know right away. Your medical team will be monitoring you closely, and it’s important to let us know about your side effects and symptoms.
Since chemotherapy targets rapidly dividing cells, it can also kill normal, healthy cells in your body that are rapidly dividing. The chemotherapy cannot tell the difference between your normal cells that rapidly divide and the cancer cells that rapidly divide. However, the cancer cells are generally affected more than the normal cells.
Cells on your skin, in your mouth, in your stomach, and your hair follicles are all examples of normal, healthy cells in your body that also divide rapidly. For this reason, chemotherapy can cause side effects in these areas of your body.
- Skin → dry or itchy skin
- Mouth → mouth sores
- Stomach → nausea, vomiting, digestion problems, reduced appetite
- Hair follicles → hair loss
The picture below is an example of some side effects that you may experience from chemotherapy. It is important to note that this is a general overview of chemotherapy side effects. Each individual chemotherapy drug has side effects that they are more likely to cause.
Although chemotherapy can cause many side effects, we are able to treat or manage the side effects. Let your medical team know if you are experiencing any side effects or symptoms.
Special Considerations
Male Breast Cancer – Treatment for metastatic breast cancer is the same in all genders and gender identities.
Birth Defects – Chemotherapy can cause severe birth defects. If you still have functioning ovaries, your doctor will likely give you treatment to prevent pregnancy. If you produce sperm, talk to your doctor about contraception to prevent your female partners from becoming pregnant.
References:
- National Cancer Institute Dictionary of Cancer Terms. cancer.gov. https://www.cancer.gov/publications/dictionaries/cancer-terms. Published February 2, 2011. Accessed September 29, 2020.
- National Cancer Institute. Metastatic Breast Cancer. nationalbreastcancer.org. https://www.nationalbreastcancer.org/metastatic-breast-cancer. Accessed September 29, 2020.
- National Cancer Institute. Metastatic Cancer. cancer.gov. https://www.cancer.gov/types/metastatic-cancer. Updated February 6, 2017. Accessed September 29, 2020.
- Gradishar WJ, Anderson BO, Abraham J, et al. National Comprehensive Cancer Network Guidelines Breast Cancer. Version 5.2020 From the National Comprehensive Cancer Network; July 2020. https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed September 29, 2020.
- Mayo Clinic Staff. Chemotherapy. mayoclinic.org. https://www.mayoclinic.org/tests-procedures/chemotherapy/about/pac-20385033. Accessed September 29, 2020.
- Lexi-drugs online [database on the Internet]. Hudson (OH): Lexicomp, Inc.; 2016 [cited 29 Sept 2020]. Available from: http://online.lexi.com. Subscription required to view.
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