Chemotherapy

What is chemotherapy?
Chemotherapy is a treatment that uses anti-cancer drugs to destroy cancer cells. It works by interfering with the cancer cells’ ability to divide and grow. Different chemotherapy drugs work in different ways and a combination of drugs is often used.
Chemotherapy affects cells throughout the body and can cause side effects. The drugs used for treating breast cancer are usually given into a vein in the hand or arm. Giving drugs this way is called ‘intravenously’.

When is chemotherapy used?

After surgery
Chemotherapy is most often given after you have had breast cancer surgery. The aim is to destroy any breast cancer cells that might have spread from your breast to other parts of your body. Chemotherapy is given after surgery for primary breast cancer to reduce the risk of cancer coming back in the future.
When used after surgery, it’s known as adjuvant chemotherapy.

Before surgery
Chemotherapy may be given before surgery to slow the growth of rapidly growing breast cancer. It can also be given before surgery to shrink a larger breast cancer before surgery, making it smaller so that it is easier to take out. This may mean breast-conserving surgery is an option, rather than a mastectomy.
People with certain types of breast cancer, such as triple negative or inflammatory breast cancer, or whose breast cancer is HER2 positive, are more likely to have chemotherapy before surgery.
Chemotherapy given before surgery is called primary or neo-adjuvant chemotherapy.

What are the side effects of chemotherapy?
The drugs used in chemotherapy can cause a lot of different side effects.

Some of the most common side effects are:

• A higher risk of infection, bruising and bleeding
• Feeling and being sick
• Your hair getting thinner or falling out
• Having a sore mouth
• Being tired
• Stopping your periods and causing an early menopause
• Lowering or stopping your chance of having a baby

Always tell your breast care nurse or treatment team how your treatment is affecting you. They can often suggest things to help make side effects easier to cope with.

Benefits of chemotherapy
The benefit of chemotherapy might be clear for some people but less clear in other cases.
Your cancer specialist may use an online program such as PREDICT to help estimate the benefit you might expect to get from chemotherapy. They may be able to show you a graph of this information, or explain the benefit as a percentage.

Genomic assays (also called gene expression profiling or gene assays).
When the benefit of chemotherapy is less certain your specialist team may suggest a test called a genomic assay. These tests look at groups of genes found in the breast cancer. They help identify who is most likely to benefit from chemotherapy and how likely the cancer is to return (recurrence).
The tests are carried out on breast tissue removed during surgery, in a laboratory outside the hospital. Genomic assays are not suitable for everyone and sometimes don’t provide a clear answer. Your specialist team will advise you whether this type of test would be useful for you.
The genomic assay tests used by Leeds Teaching Hospitals is called Oncotype DX. This test predicts how likely the cancer is to return and the likely benefit of having chemotherapy. The result, called the recurrence score, is reported as a number between 0 and 100. The higher the score, the greater the risk of recurrence of an invasive breast cancer, and the more likely it is chemotherapy will be recommended.

How long does treatment take?
You’ll normally be given your treatment at hospital as an outpatient or day case, which means you’ll be able to go home on the same day. You may be at the hospital for a short time only. However, because of tests, waiting times and how long it takes to prepare and give the chemotherapy drugs, some people are there for most of the day.
You might find it helpful to take things to help pass the time as well as snacks and drinks. You could ask someone to go with you to keep you company.

Cycles and regimes
Chemotherapy is commonly given as a series of treatments with a break between each treatment to give your body time to recover from any short-term side effects. The treatment and period of time before the next one starts is called a cycle.
You will have your treatment once every three weeks but in some cases, chemotherapy may be given weekly. Your specialist doctor will discuss this with you and advice on the best option for you.
You may have one drug or a combination of two or three drugs. The exact type and dose of chemotherapy will be tailored to your individual situation. The drugs used, the dose, how often they’re given and the number of cycles may be called your chemotherapy regime or regimen.
Intravenous chemotherapy
There are various ways that intravenous chemotherapy can be given depending on factors such as how easy it is for chemotherapy staff to find suitable veins and your preferences.

Cannula
The most common way of giving chemotherapy involves inserting a small needle and plastic tube called a cannula into a vein, either in the back of the hand or lower arm. The needle is removed and the plastic tube left in place.
The diluted drugs are slowly injected into the vein. If a large volume of fluid is used it can be given as an infusion (drip) through the cannula over a fixed period of time. The cannula is taken out after you have had the drugs and a new one is inserted before each cycle of chemotherapy.
Chemotherapy is usually given into a vein in the arm on the opposite side to where you had your surgery, as this may help reduce the risk of lymphoedema developing (swelling of the arm, hand or breast area caused by a build-up of lymph fluid). But if this isn’t possible the arm on the same side as your surgery may be used. This is also the case if you have had surgery on both sides.

Other intravenous devices
Although a cannula is the most common way of giving chemotherapy, a central venous access device is sometimes used instead. This stays in place throughout the course of the treatment and the chemotherapy is given through it.
Various types of central venous access device are described below:

Skin-tunnelled catheter (Hickman line)

A skin-tunnelled catheter is a fine silicone tube that’s inserted into a vein through a small cut in the chest.
It can stay in place for several months, which means you don’t need to have a cannula put into the vein each time you’re given the chemotherapy drugs. Blood samples can also be taken from the catheter.
The catheter is usually put in under a local anaesthetic but a general anaesthetic can be used if necessary. Your chemotherapy nurse will explain how to take care of your catheter to minimise the risk of infection. After you’ve completed all your treatment the catheter will be removed under local anaesthetic.

Peripherally inserted central catheter (PICC)

A PICC is inserted into a vein in your arm, at or above the bend in your elbow, and extends into the large vein leading to your heart. It stays in place until your whole course of treatment is finished. It’s usually put in under local anaesthetic. Blood samples can also be taken from this device.
While you have a PICC it will be covered by a dressing and you’ll be given instructions on how to care for and change this. When it’s no longer needed, the PICC will be removed by a nurse or doctor.

Blood clots
If you have a Hickman or PICC line, it’s possible for a blood clot to form in your vein at the end of the line. You may be given medication to help prevent this from happening.

Contact your hospital doctor or nurse immediately if you have any of the following symptoms:
• swelling, redness or tenderness in the arm, chest area or up into the neck
• shortness of breath
• tightness in your chest
If a blood clot forms, you’ll be given medication to dissolve it. Your line may need to be removed.

Before you start Chemotherapy
The hospital will arrange a chemotherapy information session for you. A nurse will discuss how and when your chemotherapy will be given and how side effects can be managed. You may have extra blood tests and some people might be given an ECG (electrocardiogram), a simple test that checks your heart rhythm. Your height and weight will also be measured.
You should be given a 24-hour contact number or told who to contact if you feel unwell at any time during your treatment, including at night or at the weekends.
You will be asked to sign a consent form before you start chemotherapy. The benefits and risks of the treatment should be explained before you sign.
You’ll may be given anti-sickness drugs before each chemotherapy treatment. The drugs you’re given will depend on the type of chemotherapy you’re having, but may include a steroid drug called dexamethasone as well as other anti-sickness medication.
Shortly before each cycle of treatment, and sometimes in between, you’ll have a blood test. This is because if the number of blood cells in the body is too low, treatment may need to be delayed.

Things to be aware of during treatment

Sex, contraception and pregnancy
If you haven’t been through the menopause, it’s important to use contraception because chemotherapy drugs can harm a developing foetus in the first three months of pregnancy. It’s still possible to become pregnant even if your periods become irregular or stop completely.
Your specialist will usually recommend barrier methods of contraception, such as condoms. The contraceptive pill is not usually recommended because it contains hormones. Emergency contraception such as the morning after pill can still be used.
An interuterine device (IUD or coil) can be used as long as it’s not the type that releases hormones. If you have a coil in place that does release hormones, such as the Mirena, when you’re diagnosed, you’ll probably be advised to have this removed.

Complementary therapies
Check with your specialist team or GP before having any complementary therapies, and mention your breast cancer and treatment to any therapist you see. Doctors may advise avoiding some therapies (particularly herbal remedies) if there is a chance they could affect how your breast cancer treatment works.

Travel
If you are planning a holiday or need to travel overseas, check with your specialist first.
Going abroad may not always be advisable, particularly if you have side effects or are going to a country where you’ll need live vaccine injections.
If you’re going somewhere hot, don’t stay in the sun for long periods as your skin can burn more easily when the chemotherapy drugs are still affecting your system.

Vaccinations
You shouldn’t have any live vaccines while you’re having chemotherapy. Live vaccines include measles, rubella (German measles), polio, BCG (tuberculosis), shingles and yellow fever.
Live vaccines contain a small amount of live virus or bacteria. If you have a weakened immune system, which you may do during chemotherapy, they could be harmful.
It’s safe to have these vaccines six months after your chemotherapy finishes. Talk to your GP or specialist before having any vaccinations.
If someone you live with needs to have a live vaccine speak to your specialist or GP. They can advise what precautions you may need to take depending on the vaccination.

Flu vaccination
Anyone at risk of a weakened immune system, and therefore more prone to infection, should have the flu vaccine. This includes people due to have or already having chemotherapy.
The flu vaccine is not a live vaccine so doesn’t contain any active viruses. If you’re already having chemotherapy, talk to your chemotherapy specialist or breast care nurse about the best time to have your flu jab.

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