Dealing with the Side Effects of Treatment Now and Later
The importance of finding that mutation is especially in the unaffected family members is that we could consider some extra screening to prevent cancer instead of just doing mammograms, MRI screening could be added or more careful screening for ovarian cancer can be added as well. So knowing that risk might help women who did not show (sp?) breast cancer in the family to do more intense screening. And again, all of these things are extensively discussed in high risk clinics such as we run and many other institutions have as well.
I want now to get to the information about general breast cancer treatment approach, and what happens after diagnosis. And I would like to break this down into early and advanced disease. In early disease as you know besides surgery and if necessary radiation therapy, we do discuss and see if maybe chemotherapy or hormonal therapy is indicated. The indications of chemotherapy depends on the size of the tumor, depends on if lymph nodes are involved with the tumor and the number of lymph nodes, the grade of the tumor. The drugs that we usually use in early breast cancer include anthracyclines and I’m throwing out to names right now, but thinking that you, most of you will be familiar with those. And then taxanes are commonly used drugs, cyclophosphamide, gemcitabine, abraxane, all of this, and some of the newer ones which we use.
In terms of hormonal therapy, again it depends on if the tumors have the estrogen and/or progesterone receptors. So not all of the tumors are what we call ER and or PR positive and if they are not, then the hormonal drugs such as tamoxifen or the newer versions aromatase inhibitors are not indicated and we don’t give it to our patients because there’s no benefit, and if anything, there would be more harm. And those drugs are easily taken. They are oral drugs and usually we give them for five years.
The third group of drugs we use in the adjuvant setting or early setting is Herceptin, you must have heard about that drug. It’s really not chemo, it’s not hormonal, we call it targeted therapy. It goes and binds to a protein on the tumor cells which is called the HER2neu protein, if it’s there, and then induces cell kill and kills the cancer and many studies have shown that it’s really improved the outcome of treatment.
But again, not everyone is eligible to take Herceptin because only 25% or so of breast cancers have that protein, so that drug can work. So 75% of the tumors don’t have that protein and giving Herceptin will not have an effect, if anything, again it will have side effects but not the benefit.
In terms of advanced breast cancer, I think we are luckier than many other solid tumors; we have a number of drugs available. Again the ones I just mentioned, the anthracyclines, the cytoxans, taxanes, capecitabine, navelbines, gemcitabine, are all drugs we use in the advanced setting. We also use, if indicated, hormonal management. Again the tamoxifen, aromatase inhibitors such as the main five, you know, three of them out there anastrozole (Arimidex) , letrozole (Femara), exemestane (Aromasin). Faslodex? (inaudible)is another one which we use in advanced breast cancer as well, again only when the tumor has the ER and/or PR protein.
What I said about Herceptin is also true for treating advanced disease. Again we can use Herceptin in advanced disease, as long as the tumor has the HER2 neu protein and again only 25% of the tumors have it. In the advanced setting, we actually have a little bit more targeted drugs. So besides the Herceptin, there is another drug out there which is new, lapatinib (Tykerb) is an oral drug which we use after Herceptin. It’s also a targeted drug and is not chemo, is not hormonal and has a different side effect profile. It’s a little bit easier so we have those options as well. So for advanced treatment, again we have a number of new drugs available which we use every day in our clinics.
I want to move on to the side effects of the chemotherapy and then the side effects of the hormonal therapy. It will be based on the drugs we just discussed, but I would like to break it down into acute or immediate side effects of chemo versus the longer term side effects of chemotherapy and how we manage them in our clinics.
In terms of acute, short-term side effects which I think we see pretty soon once we start the chemotherapy include gastrointestinal side effects such as nausea and vomiting. I can tell you from my experience at least, that unlike many other cancer type treatments, we don’t see that much vomiting any more because of the pretty advanced drugs available to prevent the vomiting. Nausea can happen depending on which drugs and combinations they use and the doses. However even nausea; I have really not seen any grade 3 or 4 nausea recently, maybe grades 1 and 2 in our patients, because we can control them with the group of drugs available like Compazine, Zofran is one of the drugs that even Ativan, Emend and there are some other older drugs which we sometimes use for more advanced cases as well. But I think at least from breast cancer treatment point of view, I can say that over the last 10 years we have seen really quality of life, improvement in quality of life in regards to nausea and vomiting because of the drugs we use, also proactively.
I think one important point is that we tell our patients not to wait until nausea comes and kicks in, but to start taking the drugs at the earliest signs of nausea, because it’s easier to control it before it reaches its maximum strength.
Another acute side effect could be, besides nausea and vomiting, diarrhea or constipation. And it’s interesting, some drugs cause nausea — diarrhea in some patients and constipation in others, so it most probably also depends on the person and how the body reacts to a certain drug. The diarrhea is not that bad, usually its a few days and we try to tell our patients to make sure that they drink a lot and if there’s really a lot of fluid loss, then come to our clinics for some hydration. Some of the new drugs such as Lapatinib-on e of the new targeted drugs which don’t have the side effects chemotherapy has, has actually diarrhea as a side effect, so we see the diarrhea more with the new targeted drugs rather than the chemotherapy. But again, knowing that the risk is a little bit higher, we are proactive and prescribe more anti diarrheal medications in our patients.
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