Drug Therapy for Breast Cancer

Medical oncologists in the Breast Cancer Program specialize in treating women with breast malignancies. They work with surgeons, radiation oncologists and other physicians to create drug therapy strategies that are completely coordinated with the patient’s overall care plan. 

Many women with breast cancer receive drug therapy in addition to surgery. Drug therapy for breast cancer can include chemotherapy, newer biological drugs, hormone-blocking agents and other medications.

Chemotherapy

Chemotherapy is a well-studied and effective treatment for breast cancer. It can be combined with surgery, radiation therapy and other types of drug therapy. It can also be highly personalized for each person and not everyone needs chemotherapy. Whether or not a patient needs chemotherapy depends on:

• Tumor size and grade
• Lymph node involvement
• Hormone receptor status (ER or PR)
• HER2 status
• Genomic tests (such as Oncotype DX, Mammaprint) that can help direct the need for chemotherapy

While chemotherapy can have side effects, your care team will have anti-nausea medications and other methods and resources to help you control any troubling side effects. Be sure to tell your care team about any problems.

Common side effects include:

• Hair loss — may benefit from “cold-capping,” a way to cool the scalp that may reduce hair loss
• Fatigue
• Nausea and vomiting (much better controlled than in the past)
• Low blood counts, increasing infection risk
• Mouth sores
• Changes in taste or appetite
• Neuropathy (tingling or numbness in hands/feet)

Less common side effects may include:

• Fertility changes or early menopause
• Heart effects (mainly with certain drugs)
• Cognitive changes (“chemo brain”)
• Nail changes or skin sensitivity

Cold-Capping to Reduce Hair Loss During Chemotherapy

Cold capping (also called scalp cooling) is a way to reduce hair loss during chemotherapy, and is commonly used by people being treated for breast cancer.

Cold capping involves cooling your scalp before, during and after chemotherapy infusions. It involves wearing a tight-fitting cap that is filled with frozen gel or connected to a cooling machine.

Large studies have not shown increased risk of scalp metastases, and many cancer centers now consider it safe for early-stage breast cancer.

It may not be appropriate for people with certain advanced cancers or specific chemotherapy regiments. People with cold sensitivity conditions, such as cryoglobulinemia, should not use cold-capping.

Ask your cancer care team if it is appropriate for you.

What to Expect

The cold does two things to help protect hair follicles from damage:

1. Narrows blood vessels in the scalp, so less chemo reaches hair follicles
2. Slows down follicle activity, so hair cells absorb less of the drug

Cold-capping is effective for many people, but results vary. Most people still lose some hair, but often lose much less. Some keep enough hair that others don’t notice. It can preserve your hair, but it isn’t a guarantee of zero hair loss. It doesn’t work equally well for all chemotherapy types or hair textures.

• Works best with taxane-based chemotherapies (like paclitaxel/Taxol)
• Less effective with some anthracyclines (like doxorubicin/Adriamycin)

You wear the chilled cap 30 to 60 minutes before and during chemotherapy and one to three hours after chemotherapy. The first 10 to 15 minutes can feel intensely cold and you may get a headache. Most people adjust once their scalp numbs.

Cold-capping has pluses and minuses. It is non-invasive, can help preserve hair, eyebrows, and lashes and make people feel more in control about the effects of their treatment. However, it is time-consuming (longer chemo days) and can be uncomfortable.

Cost and Insurance Coverage

Cold-capping costs vary; it typically costs $1,000 to $3,000 total. Some insurance providers cover the cost, but not all of them do. Before starting cold-capping, be sure to check with your insurance company.

Where to Get Cold-Capping

Cold-capping is available at the following Froedtert & MCW locations. Ask your care team.

• Drexel Town Square Health Center
• Froedtert West Bend Hospital

Hormone Therapy

Hormone therapy (also called endocrine therapy) is a treatment for hormone receptor–positive breast cancer—meaning cancer cells depend on estrogen and/or progesterone hormones to fuel their growth. About two out of three women have breast cancer that falls into this category. Hormone therapy only works on cancers that are estrogen receptor positive (ER+) or progesterone receptor positive (PR+). 

Hormone therapy works by lowering estrogen levels or keeping estrogen from attaching to cancer cells. The medication is usually given for at least five years.

Your care team will help you manage side effects, and if they are too troublesome, ask about adjusting the dose, substituting a different drug or taking a break and restarting after a period of time.

Hormone therapy side effects can include:

• Hot flashes
• Joint and muscle pain
• Mood changes, anxiety and depression
• Fatigue
• Changes in weight and body composition
• Bone thinning
• Vaginal dryness, pain with sex, low libido

Targeted Therapy

Targeted therapies are different from chemotherapy and hormone therapy. They are often taken as pills but some are given through the veins with an IV. They may be used alone or with other treatments like chemotherapy or immunotherapy to enhance their effectiveness. They work by going after (targeting) certain weaknesses in cancer cells such as gene mutations, proteins or signaling pathways that cancer depends on to keep growing.

Targeted therapies require testing the tumor tissue to evaluate it for specific targets this type of therapy can treat. The targeted therapy is chosen based on tumor biology, not just the stage of your cancer. It only works if there are vetted targets in your cancer cells.

Side effects should reported to your care team, so they can provide resources to help you cope with them. Your quality of life is Side effects of targeted therapies may include:

• Fatigue
• GI issues
• Skin hair or nail issues
• Low blood counts
• Brain fog and concentration issues
• Heart-related effects (not common, usually reversible, monitored with heart scans
• Metabolic changes
• Immune and infection-related issues

Immunotherapy

Immunotherapy uses the power of your own immune system to treat cancer. For breast cancer, it is a newer therapy that helps your own immune system detect and eliminate cancer. It is not a treatment for people with all types of breast cancer.

The strongest evidence for immunotherapy use is with people who have triple-negative breast cancer (TNBC). It may be considered if the TNBC is early stage and higher risk (often combined with chemotherapy before surgery). It could also be an option in patients who have metastatic TNBC if their tumor meets select criteria.

Tests of the tumor’s biology will help determine eligibility if your care team thinks you may benefit from immunotherapy. Your cancer subtype and cancer stage are other factors that will be considered.

Side effects of immunotherapy are not typically severe, although some side effects can become serious. Side effects can appear after one dose or after you have been on immunotherapy for some time – even after stopping treatment. Your care team will tell you it’s essential to tell them right away if you are having troubling side effects or anything feels “off,” so they can help you. Early intervention is important, so don’t wait.

Mild to moderate issues may include:

• Fatigue
• Skin rash or itching
• Achy joints
• Diarrhea
• Thyroid changes

Less common side effects are immune-related and can be serious. They may include:

• Thyroid inflammation
• Colitis
• Lung inflammation Liver inflammation
• Skin reactions
• Adrenal or pituitary gland issues

Adjuvant Therapy

Even after tumor tissue has been surgically removed and the patient has received radiation therapy, it is possible that microscopic cancer cells have spread to other parts of the body. Many breast cancer patients receive adjuvant drug therapy — drugs given after surgery to kill any metastatic cancer cells and decrease the chance of cancer coming back (recurrence).

Preoperative Drug Therapy

Drug therapy before surgery, also called neo-adjuvant therapy, is used to reduce the size of the tumor before surgery. For some women, shrinking the tumor may make a breast-conserving surgery possible (a lumpectomy instead of a mastectomy).

For other women, reducing the size of the tumor could be key to making surgery possible at all. Giving drugs before surgery can also help medical oncologists find out how sensitive a patient’s tumor is to drug therapy. This is information that could be useful when making later treatment decisions.

Drug Therapies for Metastatic Disease

Breast cancers that have spread to other parts of the body are treatable, and drug therapy can extend survival for many patients. Drug options for metastatic disease include several of the drugs that are also used to treat patients with earlier stage breast cancer. . Drugs that block bone metastases are also available.

Tailoring Drug Therapy to Tumor Types 

Medical oncologists are increasingly able to personalize drug therapies based on the molecular characteristics of tumors. By identifying certain genes that are present at higher levels within the cells of a patient’s tumor, physicians can figure out how the tumor might behave and drugs that might be helpful in fighting the cancer.

It is important to know that tumor gene profiling examines the abnormal genes present in a patient’s tumor. It is different from BRCA testing, which looks at a woman’s normal cells to determine her genetic risk of developing breast cancer.

Tumor gene profiling can guide drug therapy decision-making for several known tumor types:

HER2-Positive Tumors

HER2 is a protein found in some normal cells within the human body. In normal cells, HER2 plays a key role in cell growth. In about 25 percent of breast cancers, HER2 is present at abnormally high levels, which causes the tumor to grow rapidly. Women with this type of breast cancer can benefit from taking biological drugs that block the action of HER2. Trastuzumab (Herceptin) is a HER2-inhibitor used with chemotherapy for women whose cancer is still confined to the breast. Multiple other HER2-directed drugs are now available in addition to trastuzumab.

Hormone-Sensitive Tumors

In about 80 percent of breast cancers, estrogen and progesterone receptors are found in the cells of the tumor. If these receptors are present, it is likely that the tumor needs hormones for cell growth and that hormone-blocking agents will slow or stop the cancer’s growth. One medical option is tamoxifen, a drug that binds to the cancer cell’s estrogen receptors, preventing a tumor from receiving the hormone.

Post-menopausal women can also receive aromatase inhibitors, drugs that block the body’s production of estrogen. Drug therapy can also be used to “turn off” the ovaries, and for some women oophorectomy (the surgical removal of the ovaries) is an option.

Tumor Gene Profiling to Guide Treatment Decisions

Some tumor gene tests can help physicians understand which patients are likely to benefit from certain therapies and which would not. For example, patients with breast cancer that has not spread to the lymph nodes have a generally low risk of recurrence. Yet, for a large number of these women, the cancer will return. A test called Oncotype DX profiles 21 genes in the cancer tumor to help distinguish patients with a truly low risk of recurrence from those who need and would benefit from chemotherapy. Another similar test called Mammaprint is a 70 gene assay assessing risk of recurrence and if chemotherapy is needed.