Reducing Chemotherapy Side Effects

Erica Heilman
One of the most difficult challenges women face in breast cancer treatment is learning to manage treatment side effects. Most often, surgery is performed to remove the tumor, but treatment usually involves some type of follow-up therapy to kill breast cancer cells that may remain behind. The type of treatment cancer specialists recommend often depends on the type of breast cancer and whether a woman has entered menopause. Two-thirds of women with breast cancer are "hormone-receptor positive." which makes them good candidates for hormonal therapy, and these new therapies do not cause the discomfort that commonly accompanies chemotherapy treatment. But treatments for a number of side effects traditionally associated with chemotherapy have also improved, making the experience of chemotherapy more manageable.

Below, three breast cancer experts talk about the role that chemotherapy plays in early-stage breast cancer, and what can be done to stave off some of the more common side effects of chemotherapy.

Where role does chemotherapy play in treating early-stage breast cancer?
GENEROSA GRANA, MD: Surgery and radiation address local cancer cells in the chest. They do nothing in terms of systemic risk?risk of spread and recurrence of the cancer elsewhere in the body. The majority of women need additional treatment to address those issues. You address these risks by focusing on chemotherapy, hormone therapy or a combination of the two.


What is hormonal therapy for breast cancer?
WILLIAM J. GRADISHAR, MD: The majority of all breast cancers are influenced in one way or another by the presence of hormones that normally circulate in the body, and many of these tumors express what are referred to as estrogen and progesterone receptors, or hormone receptors. If present, they identify tumors in women that are potentially influenced by the presence of hormones. There are a smaller percent of patients who develop breast cancer without those receptors and we refer to those as hormone-insensitive tumors. Hormone therapy interferes with the influence of hormones on hormone-sensitive breast cancers. In effect, hormonal therapy stops the cancer from growing, where chemotherapy kills the actual cancer cells.

How does chemotherapy work in the body?
WILLIAM J. GRADISHAR, MD: Chemotherapy is used to eliminate or kill microscopic disease that may still remain after a patient has undergone surgery on her breast?either a mastectomy or a lumpectomy?followed by radiation therapy. So it?s not meant to address disease that we can see or measure with a scan. It?s meant to eliminate microscopic disease that we think is there based on the size of the tumor or the number of lymph nodes and it?s a statistical probability that a given patient may have residual disease. So chemotherapy?s meant to go everywhere your blood goes; it?s meant to eliminate microscopic deposits of tumor cells.
What are some of the basic considerations in making treatment decisions?
AMAN BUZDAR, MD: I think the first thing patients have to understand is that if their cancer is hormone receptor-negative, there is only one choice they have to make. Are they going to take chemotherapy or not take chemotherapy? If the cancer is hormone receptor-positive, then the patient has three choices: chemotherapy alone, hormone therapy alone, or a combination of both.

What are some of the side effects that women taking chemotherapy can expect?
WILLIAM J. GRADISHAR, MD: The side effect profiles are generally fairly predictable and they vary, depending on the recipe and dose of drug used or what the interval is between individual treatments. Two of the things that happen consistently are hair loss and falling blood counts. The blood counts start out normal, dip down midway in treatment and then they come back up to normal.

AMAN BUZDAR, MD: When the blood count is low, patients may develop an infection or may have bleeding. All those things are manageable. If they develop fever, an antibiotic makes it better. But if the patient has a fever while she has a low blood count, she needs to address it right away. She might think, "Oh today is Friday. I?ll call my doctor on Monday." But the infection may be overwhelming and the patient may not understand the seriousness of it until she becomes too sick.


Women who are taking chemotherapy have to understand that if they have any degree of fever, they need to talk to the doctor or need to go and see the doctor to make sure that they are not at risk of getting very sick. Fortunately, we have medications that are effective in reversing the low blood counts.

Is hair loss unavoidable?
GENEROSA GRANA, MD: Hair loss, unfortunately, cannot be managed, and although there are many anecdotal tales of things that can be done, they don?t really work.
WILLIAM J. GRADISHAR, MD: And it should be emphasized that we do want the chemotherapy to go everywhere, and that includes the skin in the scalp. Spread of the breast cancer to the skin, though rare, can occur anywhere, so if you use a cooling cap to try and prevent hair loss, that cap causes vasoconstriction?a clamping down of the blood vessels?and the chemotherapy doesn?t get there.
So although hair loss is an unfortunate consequence of chemotherapy, it?s one of the things we can?t really solve. But your hair does grow back at the completion of chemotherapy.

Are there any cardiovascular side effects that women need to be aware of?
AMAN BUZDAR, MD: The anthracycline-based chemotherapy drugs do cause small damage to the heart muscle. But the doses of the drugs given to the patient pose only a small risk. That?s why we have to look at the risk versus benefit ratio. If the risk of cancer recurrence is very great, then the small cardiovascular risk associated with the chemotherapy is counterbalanced. The odds of the patient remaining alive are much greater with the chemotherapy than without.

What risk does chemotherapy pose to fertility?
WILLIAM J. GRADISHAR, MD: Chemotherapy can disrupt the function of a woman?s ovaries. If the woman is approaching menopause, there?s a very good chance that chemotherapy will push her into menopause. On the other hand, if a woman is in her thirties or forties, chemotherapy is less likely to affect a woman?s fertility, though there is no absolute guarantee.


AMAN BUZDAR, MD: The older the woman, the higher the likelihood that her ovaries will stop functioning. Younger women receiving chemotherapy may quit menstruating, but for many of them, ovarian function will return back to normal. We have a number of women who have given birth normally after they have taken chemotherapy.

Is there any way to protect the function of the ovaries?
GENEROSA GRANA, MD: The protection of ovarian function is very difficult to do. There have been small studies that have suggested that by shutting down the ovary with a monthly injection?a drug called Lupron?you may be able to preserve ovarian function. Whether that ultimately will allow the woman to be able to have children long term is not as clear.

Is fatigue a common side effect of chemotherapy?
AMAN BUZDAR, MD: Fatigue is very common. Red blood cell counts might become low with chemotherapy, but, there are effective drugs that can reverse anemia, which can help with fatigue.

Is nausea still a problem with chemotherapy?
WILLIAM J. GRADISHAR, MD: Nausea and vomiting are generally complications of the past rather than the present. It doesn?t mean that a woman won?t experience some queasiness, maybe not feel quite right, but the drugs that we now use to help with these problems?both before chemotherapy is given and for patients to take home with them?have largely eliminated nausea and vomiting. And most women do fine during their treatment.

What are some of the less serious side effects of chemotherapy?
GENEROSA GRANA, MD: Some women will complain of constipation, some women will have diarrhea. Mouth sores can be problematic. Changes in the nail beds are very common, or in the skin, very common.

What advice would you give someone beginning treatment?
AMAN BUZDAR, MD: With careful monitoring and medication, most of these side effects can be effectively managed. I advise my patients to write down what they experience in each cycle. If they have side effects, we can often offer them effective treatments.


Dr. Generosa Grana is the Director of the Breast Cancer Program at Cooper Hospital in Camden, New Jersey

Dr. Bill Gradishar is the Director of breast oncology at the Feinberg School of Medicine, Northwestern University.

Dr. Aman U. Buzdar is a Professor of Medicine for the Department of Breast Medical Oncology at the University of Texas M.D. Anderson Cancer Center in Houston, Texas.

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