TREATING EARLY BREAST

CANCER Debbie Bajrovic

Oncology PharmacistMount Hospital Pharmacy

ADJUVANT AND NEO-ADJUVANT THERAPY FOR EARLY BREAST CANCER Adjuvant therapy is any treatment given

after primary surgery. Neo-Adjuvant therapy is any treatment

given before primary surgery. Therapy can include: chemotherapy hormonal therapy the targeted drug Trastuzumab

(Herceptin) radiation therapy or a combination of treatments

CUSTOMISED CARE Stage of the cancer (size/position) Grade of the cancer (how closely the

tumour cells resemble normal cells) Your age Menopausal status Whether lymph nodes are effected HER2 status Hormone receptor status

CHEMOTHERAPY Use of anti-cancer (cytotoxic) drugs to

destroy cancer cells Usually administered intravenously as an

outpatient Treatment can take a number of hours Treatment cycles can be weekly, fortnightly

or three weekly depending on the drugs used

There is a rest period between cycles to let your body recover from side effects

A complete course is likely to take 4-6 months

CHEMOTHERAPY DRUGS USED IN EARLY BREAST

CANCER Fluorouracil (5-FU) Epirubicin (Epi) Cyclophosphamide (Cyclo) Docetaxel (Taxotere) Carboplatin (Carbo) Doxorubicin (Dox) Paclitaxel (Taxol)

HERCEPTIN IN EARLY BREAST CANCER

Trastuzumab (Herceptin) – tests are done to see if you are HER 2 +ve (overexpress HER 2)

If you are HER 2 +ve you will be given Herceptin with your chemotherapy.

Treatment may start immediately with chemotherapy or be delayed a few weeks

When chemotherapy finishes you will continue to have Herceptin for a total of 52 weeks.

HORMONAL THERAPIES IN EARLY BREAST

CANCER Hormonal therapies only work in women whose

cancer cells have receptors for oestrogen and/or progesterone on their surface. ER+ or PR+

Hormonal therapy deprives the cancer of the hormone oestrogen which many breast cancers need to grow.

They are given after chemotherapy to reduce the chance of the cancer coming back.

Tamoxifen blocks oestrogen activity in the body Letrozole(Femara), Exemestane(Aromasin) and

Anastrozole(Arimidex) stop the body from making oestrogen

Goserelin (Zoladex)

CLINICAL TRIALS Patients may be offered a choice of

chemotherapy treatments, as different drug combinations can cause different side effects.

Some patients may be offered to go on a clinical trial.

Clinical trials are carried out to compare different types of therapy, to improve effectiveness and reduce side effects.

CHEMOTHERAPY COMBINATIONS IN EARLY

BREAST CANCER Chemotherapy drugs are often used in

combination. These are called chemotherapy regimens or protocols.

FEC (5-FU, Epirubicin, Cyclophosphamide x 6)

FEC-D(T) (FEC x 3- Docetaxel x 3) AC-T(H) (Doxorubicin, Cyclo x 4 – Taxol x

4) TAC (Docetaxel, Doxorubicin, Cyclo x 6) TCH (Docetaxel, Carboplatin, Herceptin

x 6) TC (Docetaxel, Cyclophosphamide x 4)

CHEMOTHERAPY PRE-MEDS

Pre-meds are given prior to chemotherapy to help reduce hypersensitivity reactions and side effects.

They are given orally and intravenously starting the day before chemotherapy or just prior to chemotherapy

Antiemetic's, steroids, antihistamines and pain killers are used.

Mostly to prevent nausea, fluid retention and allergy

They can cause headaches and constipation

DRUGS USED AS PRE-MEDS

Dexamethasone – steroid used to prevent nausea and fluid retention. Given IV just prior to chemotherapy and orally up to three days after. Sometimes taken twice a day starting the day before chemotherapy

Kytril – (Granisetron) given IV just prior to chemotherapy and orally in the morning on days 2 and 3

Phenergan – (Promethazine) given IV just prior to chemotherapy to help prevent an allergic reaction

Panadol – (Paracetamol) for pain and fever

DRUGS FOR NAUSEA AND VOMITING

Maxolon – (Metoclopramide, 10mg) used for breakthrough nausea and vomiting. 1-2 tablets up to 4-6 hourly.

Stemetil – (Prochlorperazine, 10mg) 1 tablet every 4 to 6 hours for breakthrough

Stemetil Suppositories – (Prochlorperazine) 25mg rectally every 12 hours.

Ativan – (Lorazepam, 1mg) – 1 tablet placed under the tongue every 4 to 6 hours if needed for breakthrough nausea.

HAEMATOLOGICAL SIDE EFFECTS OF

CHEMOTHERAPY Neutropenia - reduced numbers of white blood cells

which can lower resistance to infection - can begin 7 days after treatment and reaches its lowest point 10-14 days after chemotherapy. - WBC usually increase steadily and return to normal before your next cycle. - Contact your doctor if your temperature goes above 38 C or if you suddenly feel unwello Neulasta – Injection given 24 hours after

chemotherapy which stimulates the level of white blood cells (neutrophils). This can allow frequent dosing of chemotherapy and diminish tumour regrowth.

HAEMATOLOGICAL SIDE EFFECTS OF

CHEMOTHERAPY Bruising or bleeding – reduced numbers of

platelets which help the blood to clot - contact your doctor if you have unexplained bruising or bleeding such as nosebleeds or bleeding gums

Anaemia – low red blood cell count - may make you feel tired or breathless

COMMON SIDE EFFECTS OF CHEMOTHERAPY

Nausea or vomiting Diarrhoea/Constipation Tiredness or fatigue Hair Loss – usually starts 2 -3 weeks after you

start your chemotherapy. Thinning of the eyelashes, eyebrows and other body hair may also occur. Hair loss is temporary.

Sore mouth and ulcers – your mouth may become sore or dry. Drink plenty of fluids, clean teeth regularly with a soft brush, floss daily. Use mouthwashes regularly (half a teaspoon of salt or bicarbonate of soda in a glass of water) Cryotherapy

COMMON SIDE EFFECTS OF CHEMOTHERAPY

Taste changes Irritation of the bladder –

cyclophosphamide Pink urine – Doxorubicin/Epirubicin Skin changes Sensitivity to the sun – use sunscreen/hat Fluid retention Nail changes Allergic reactions Pain in joints or muscles Numbness or tingling in hands and feet

SIDE EFFECTS OF HERCEPTIN

Flu-like symptoms Diarrhoea Headaches An allergic reaction Cardiotoxicity – usually mild and

reversible

SIDE EFFECTS OF HORMONAL THERAPIES

Hot flushes Vaginal dryness or itching Loss of libido Psychological effects Joint aches or pains