Decisions Regarding Chemotherapy for Breast Cancer
Dr. Gary Pansegrau, FRCPC, BC Cancer Agency, Fraser Valley Centre

Doctor, what is the best chemotherapy for me? is a common question asked of me as a Medical Oncologist. Multiple patient and chemotherapy related factors must be considered when addressing this question. Your Medical Oncologist will take into account the specific features of your cancer, your other medical conditions, and the potential side effects of the treatment in making this decision with you.

The goal of treatment in early stage breast cancer, that is cancer limited to the breast and/or axillary (armpit) lymph glands, is to lower the chance that the breast cancer will recur (spread to another part of the body) and thereby improve survival. There are many possible chemotherapy regimens for early stage breast cancer and most commonly the chemotherapy is given intravenously once every three weeks for 4 to 8 cycles.

Chemotherapy will cause side effects, and all of the common regimens result in hair loss, fatigue, a risk for nausea, vomiting and the development of infections. Some of the regimens have a small risk of causing heart muscle damage and/or the development of blood disorders including leukemia. Some regimens result in more muscle aches and pains, as well as tingling, numbness, and possibly pain in the fingers and toes due to nerve damage (neuropathy). Chemotherapy may also temporarily, or permanently, stop a women's menstrual cycle and thereby could lead to infertility. Medical Oncologists factor in the risk of developing specific side effects as well as a patient's pre-existing symptoms and medical illnesses in making a chemotherapy recommendation.

But how do Medical Oncologists decide which chemotherapy regimens to recommend? The recommendation for specific chemotherapy regimens is based on the results of well designed and peer-reviewed clinical trials. In a clinical trial, half of the patients receive treatment A, and the other half receives treatment B. The patients are closely monitored for years to determine which treatment A or B results in better patient outcomes and to closely document serious side effects. If treatment B is superior, the next clinical trial will compare treatment B (the new standard) to a new regimen, say treatment C, in a continuous process of trying to improve breast cancer treatments.
Who pays for the chemotherapy? In British Columbia the cost of the chemotherapy is paid for by the BC Cancer Agency through funding from the provincial government. However, nausea medications are not covered and a patient must pay for these medications directly or use their extended medical coverage plans to cover the cost. If a patient's white blood cell count does not recover before the next chemotherapy cycle, or if they develop an infection on chemotherapy the Medical Oncologist will often discuss the option of using another medication, called filgrastim (or G-CSF) to help stimulate the recovery of the white blood cells. This medication is also not paid for by the Cancer Agency, however, the drug company that makes this medication has a program in place that may offer some assistance based on financial need.

For patients with metastatic breast cancer, that is, cancer that has spread beyond the breast or local lymph nodes, there are also many treatment related decisions that must be considered. The goal of treatment for patients with metastatic disease is to try to shrink tumor masses, to improve quality and length of life, and to minimize treatment related side effects. Hormone blocking agents are commonly used in women with breast cancers that are estrogen receptor (ER) or progesterone receptor (PR) positive. When chemotherapy is used, most commonly one chemotherapy drug is used at a time for 3-6 cycles, occasionally two drugs are used at the same time; however the side effects tend to be more significant. Some chemotherapy drugs cause little or no hair loss while others cause significant hair loss. Only one commonly used chemotherapy drug is available as a pill, whereas the other frequently used drugs are given intravenously. Some of the drugs cause more nausea and others cause more aches and pains and tingling and numbness in the fingers and toes. Thus, there many options available and treatment is tailored to each patient's particular circumstance.

In summary, treatment decision making in early and metastatic breast cancer is complex and requires input from both the Medical Oncologist and the patient. Treatment is tailored to the individual patient's situation with the goal of maximizing benefit and minimizing side effects.

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