Chemotherapy - A Detailed Overview                                                                  Chemotherapy                       http://www.breastcancer.org/tre_sys_chemo_idx.html Chemotherapy is a systemic therapy; this means it affects the whole body by going through the bloodstream. The purpose of chemotherapy and other systemic treatments is to get rid of any cancer cells that may have spread from where the cancer started to another part of the body. Chemotherapy is effective against cancer cells because the drugs love to interfere with rapidly dividing cells. The side effects of chemotherapy come about because cancer cells aren't the only rapidly dividing cells in your body. The cells in your blood, mouth, intestinal tract, nose, nails, vagina, and hair are also undergoing constant, rapid division. This means that the chemotherapy is going to affect them, too. Still, chemotherapy is much easier to tolerate today than even a few years ago. And for many women it's an important "insurance policy" against cancer recurrence. It's also important to remember that organs in which the cells do not divide rapidly, such as the liver and kidneys, are rarely affected by chemotherapy. And doctors and nurses will keep close track of side effects and can treat most of them to improve the way you feel.. It's important to remember that every woman's ideal treatment plan is different. Be aware that your "chemo" regimen may be different from someone else's, based on very individual—and sometimes subtle—breast cancer factors. These include: lymph node involvement, tumor size, hormone receptor status, grade, and oncogene expression. Be prepared for your doctor to recommend a combination of chemotherapies—together or in a series. How Chemo Works Chemotherapy is the use of drugs to treat cancer. Before surgery, chemotherapy may be used both to reduce the size of the breast tumor and to destroy cancer cells wherever they may be. After surgery, chemotherapy works throughout your system to kill cancer cells that may have spread throughout your body. Here's how this systemic treatment works. Your body's normal cells grow and divide in a controlled manner. Cancer cells, however, grow and divide in total chaos—without any control or logical order. Chemotherapy works by stopping the growth or multiplication of cancer cells, thereby killing them. There is a possibility that you may worry that chemotherapy will kill normal cells, too, and there is that possibility. However, remember that these drugs work best on cells that divide rapidly—namely, cancer cells. This makes chemotherapy particularly effective against cancer. When used as systemic therapy right after surgery, chemotherapy has another advantage: being in the right place at the right time. Let's say that cancer cells have broken away from the primary tumor, and that these relatively young and small clusters are now located somewhere in your body. These single cells or small clusters have plenty of nutrients and oxygen, and they are dividing quite rapidly (by contrast, with larger tumors the cells are crowded together, there isn't enough food to go around, and the cells don't have the energy to grow). This is perfect timing for chemotherapy because, remember, chemotherapy works best on rapidly dividing cells. And this is why cancer cells are much more sensitive to chemotherapy than normal cells. A "cycle" of chemotherapy refers to one time or one "round" in which you go to the doctor and receive the medication. A "course" of chemotherapy refers to all the cycles in your entire treatment. Depending on the drug (or drugs) you receive, you may have anywhere from four to eight cycles of chemotherapy during an entire course. Why So Many Drugs? Chemotherapy is often given as a combination of drugs rather than one single agent. This is because cancer tumors are "heterogeneous"—made up of many different kinds of cells that may have different vulnerabilities to "attack." Chemotherapy is often given as a combination of drugs rather than one single agent. It's like taking a combination cold pill that is designed to fix runny nose, aching joints, fever, AND cough. You want to be able to knock out any type of cell that might still be in your body, no matter what its vulnerable spot might be. This combination approach creates the "alphabet soup" of systemic treatment options. Here are a few commonly used combinations. Chemotherapy combinations for non-metastatic breast cancer AC ± T – Adriamycin (chemical name: doxorubicin) with cyclophosphamide (brand name: Cytoxan), with or without Taxol (chemical name: paclitaxel) or Taxotere (chemical name: docetaxol) CMF – cyclophosphamide, methotrexate, and fluorouracil ("5-FU" or 5-fluorouracil) CAF – cyclophosphamide, Adriamycin, and fluorouracil ("5-FU" or 5-fluorouracil) CEF – cyclophosphamide, Epirubicin (similar to Adriamycin), and fluorouracil ("5-FU" or 5-fluorouracil) FAC – fluorouracil ("5-FU" or 5-fluorouracil), Adriamycin, and cyclophosphamide. How these regimens compare to each other depends on a variety of things: the tumor size, growth rate, and grade; whether lymph nodes are involved; whether you have had previous treatment with any other combination of drugs; and your oncologist's experience with and preferences for particular regimens There have been some comparison studies of these regimens, although not all of the various combinations been tested against one another.               A study that compared CEF to CMF found that CEF was more effective in    lowering risk of recurrence and increased chances of survival from the disease for pre-menopausal women with node-positive disease. A five-year study of women with node-positive, early-stage disease showed that TAC (AC+T) was more beneficial than FAC in lowering the risk of cancer coming back as well as longer overall survival. Many new advances in the field offer you and your physician a wider range of options, depending on your particular situation. Every woman and every cancer are different and respond differently to treatment. Every cell of any particular cancer originated from the same "mother" cell. One cell turns into two cells, two cells to four, and so on. By the time a one-centimeter cancer is detected, the millions of cells that make up the lump have become distant relatives, as different from each other as you may be from your third cousin twice removed. Such cancer cell diversity—represented by the red stars, blue circles, and green triangles in this illustration—is called "tumor heterogeneity." Because what kills one kind of cell might pass over another, we need treatments in combination or in sequence, working in different ways, that TOGETHER may eliminate all of the cancer. Classes of Drugs Chemotherapy drugs for non-metastatic and metastatic breast cancer fall into several categories. ·         Alkylators affect cancer cells much like radiation does: by damaging the proteins that control growth in the genes of the tumor cell. Cyclophosphamide (the "C" in CAF, CMF, CEF, and FAC) is the most commonly used alkylating agent. It can be given intravenously (IV) (in the veins) or orally (by mouth). ·         Antimetabolites act as false building blocks in a cancer cell's genes, causing it to die as it gets ready to divide. Fluorouracil, or 5-FU, is an antimetabolite,Fluorouracil, or 5-FU, is an antimetabolite, as is Gemzar (chemical name: gemcitabine). ·         Antibiotics (not to be confused with antibiotics that fight infection) include potent inhibitors of gene replication. ("Anti" means "against," and "biotic" means "growth.") Adriamycin is the most commonly used drug in this category, and is often combined with Cytoxan (cyclophosphamide). (Adriamycin belongs to a group of drugs called anthracyclines.) ·         Antimiotic agents or natural agents rob cellular genes of the ability to reproduce themselves during division. One example of an antimiotic is vincristine (brand name: Oncovin), which comes from the periwinkle plant. Vinorelbine (brand name: Navelbine) comes from the same plant but is chemically altered in a way that reduces the side effects. ·         Antimicrotubule or natural agents interfere with cell structure and cell division. Taxol (paclitaxel) and Taxotere (docetaxel), two examples of drugs from this group, are produced from the bark of the yew tree. Who Gets Chemo? Doctors use many factors to determine who receives chemotherapy, hormonal (anti-estrogen) therapy, or a combination of both. A new test may be able to help you make choices about treatments. These factors are: ·         key features of the particular cancer, including tumor size and grade, hormone receptor status, rate of tumor cell growth, oncogene expression, and lymph node involvement; ·         individual patient profile (age, general health, location of tumor, whether or not there are enlarged lymph nodes under the arm); ·         stage of the disease; ·         menopausal status (whether you are still menstruating or had already stopped menstruating when the cancer was diagnosed); and ·         risk/benefit factor of the treatment. Your medical oncologist will weigh the risks that you face from cancer versus the long-lasting benefits you could realize from the chemotherapy or hormonal (anti-estrogen) therapy, taking into account the treatment's side effects and your general health picture. As you and your doctor analyze the information from all of these factors, you'll discuss several widely accepted treatment guidelines. Remember that in determining who receives chemotherapy, every individual's case is different and requires specific consideration by a medical oncologist. ·         Chemotherapy is never recommended for non-invasive, in situ cancers, which have nearly no risk of metastasizing (spreading to other parts of the body). Effective treatment targeting the breast, rigorous observation, and follow-up are critical. Anti-estrogen therapy is usually considered for its protective effect on the remaining breast tissue. ·         In general, doctors tend to recommend more aggressive treatments in women with invasive breast cancer who are pre-menopausal (still menstruating). Breast cancer in these women tends to be more aggressive, and chemotherapy is usually required in order to achieve the best results. ·         Chemotherapy is almost always recommended if the lymph nodes are involved, regardless of the size of the tumor or menopausal status. ·         Chemotherapy is usually recommended for pre-menopausal women if the tumor is invasive, has not spread to the lymph nodes, and is one centimeter or more in size. With these factors present in a post-menopausal woman, chemotherapy would be seriously considered. ·         Chemotherapy MAY be recommended to women (especially pre-menopausal women) who have a combination of favorable and less-than-favorable cancer characteristics—for example, if the tumor is invasive, is confined to the breast, is smaller than one centimeter, but has one or more unfavorable "personality features." Hormonal therapy in addition to chemotherapy ·         Hormonal (anti-estrogen) therapy should be considered in any PRE-menopausal woman whose cancer is estrogen-receptor-positive. Decisions about chemotherapy and hormonal therapy are coordinated. Some women get chemotherapy alone, others hormonal therapy alone, and still others get both forms of treatment. ·         Chemotherapy in addition to hormonal therapy may help lower the risk of recurrence for some estrogen-receptor-positive cancers that also have unfavorable factors. For example, a new test (not yet widely available) shows the levels of "invasion factors" uPA and PAI-1 in the cancer. High levels are considered unfavorable. Another new test called Oncotype DX helps assess risk of recurrence in women with hormone-receptor-positive disease who have completed a course of treatment with tamoxifen. For women at high risk, adding chemotherapy may be beneficial. ·         Women with estrogen-receptor-NEGATIVE cancers (the tumors do not need estrogen to grow) will do as well with chemotherapy alone as they would if they followed chemotherapy with hormonal treatment. ·         Hormonal therapy is recommended to nearly all post-menopausal women with estrogen-receptor-positive or progesterone-receptor-positive breast cancer. Managing Chemo Side Effect Chemotherapy is effective against cancer cells because the drugs love to interfere with rapidly dividing cells. Unfortunately, cancer cells aren't the only rapidly dividing cells in your body. The cells in your blood, mouth, intestinal tract, nose, nails, vagina, and hair are also undergoing constant, rapid division. This means that the chemotherapy is going to affect them, too. These body parts, however, have an advantage over cancer cells in that your body can repair the damage that chemotherapy does to your normal cells. This explains why your hair will grow back, your energy levels will rise, and your infections will clear up. And while your body is fighting back, supportive medications can help you control many of the side effects of chemotherapy. While many side effects of chemotherapy fade quickly, others may take months or years to disappear completely. For example, some women experience discomfort in their hands and feet from nerve damage related to the taxanes (Taxol or Taxotere), which can persist for months. It is possible (though uncommon) that chemotherapy may cause permanent side effects. Considering these possible side effects is part of the careful process of weighing benefits versus risks that you will have to do with your medical team. Here are some of the more serious potential side effects that you will want to be aware of and discuss carefully with your oncologist: ·         Chemotherapy can lead to bone loss. Women past menopause do not produce enough hormones to maintain strong bones. Over time, thinning bones may develop into osteoporosis and increase your risk of serious fractures If you are still pre-menopausal when you begin chemotherapy, your ovaries may stop making hormones, putting your bones at risk. The combination CMF is more likely to stop the ovaries from making hormones compared to treatment that contains Adriamycin. ·         The taxanes Taxol and Abraxane can cause more discomfort in the hands and feet from nerve damage than Taxotere. This can be temporary or permanent. Your doctor may refer to this as neuropathy. Lowering the dosage of Abraxane improves the neuropathy in most women. ·         Taxotere has also been found to irritate tear ducts and cause excess tearing. If it persists and bothers you, it can usually be treated by inserting tiny silicone tubes into the "pipes" that drain the tears. ·         Adriamycin can have a toxic effect on the heart; your doctor will work to minimize this risk by carefully keeping your total drug dosage within a safe range. ·         In very rare cases, cyclophosphamide (brand name: Cytoxan) may cause a treatment-induced leukemia (cancer of the blood cells). It's impossible to list the specific side effects of every medication. Your experience with a particular drug is strongly influenced by what you've already been through and what other drugs you're taking at the same time. You and your doctor are the only people who can determine whether the expected benefits from your chemotherapy outweigh any problems you may be having. And your doctor can give you the most realistic sense of what to expect. Here's a look at the most common side effects of chemotherapy, as well as medications and lifestyle suggestions that can help you cope with them. Nausea, vomiting, and diarrhea Hair loss Fatigue and anemia Infections Mouth sores Taste and smell changes Menopause and fertility Memory loss Nausea, Vomiting, and Diarrhea Some people never have nausea or vomiting. Others are nauseated every day of treatment. Many people describe having "stomach awareness," where they find they are not interested in eating, but do not feel nauseated. Some people have nausea that lingers more than a week beyond chemotherapy. Thankfully, these side effects can almost always be controlled, or at least substantially reduced, by a variety of drugs and lifestyle changes. Nausea makes most people feel anxious. And this anxiety can make the nausea worse. For example, the normal uncertainty and worries about the first chemotherapy can make this treatment harder than the others. The same emotional factors that can cause nausea or diarrhea before a test or seeing your doctor can also lead to more nausea before chemotherapy. Plus, anxiety can cause indigestion and heartburn, making matters worse. Watch out for other things that can contribute to nausea, like constipation and prolonged coughing (from bronchitis or a bad cold). Sometimes nausea can also be a side effect of pain medications. Before chemotherapy starts, it's important to understand nausea and all the factors that can affect it. By being informed and working closely with your health care team, perhaps you can avoid nausea entirely. One way to be prepared is to ask your doctor for a prescription for anti-nausea medication ahead of time. That way, you can have the medication ready in case you need it right after chemotherapy treatment, and you won't have to spend precious time waiting at the pharmacy. If you're worried about paying for anti-nausea medicine, ask your doctor for any free samples. Mild nausea For some people, sniffing a cut surface of fresh ginger can help with mild nausea. Remember using ginger ale when you were sick as a kid? You might get the same benefit when you smell ginger during chemotherapy. Some people claim that the "sea band" worn on boats or airplanes can help ease nausea. These are available at most larger drug stores. Make sure you read the directions carefully so that you know where the band should go. Nausea or queasiness from anxiety can be improved with both mindful measures and medications. Visualization and meditation can be particularly helpful. Acupuncture can also be quite effective at relieving nausea. Acupuncture can also be quite effective at relieving nausea. In a study of women who had high-dose chemotherapy before having bone marrow transplants, acupuncture proved helpful. Those who had electroacupuncture (insertion of stainless steel needles that were then stimulated with electric current) got more relief from their nausea than those who had acupuncture without stimulation or no acupuncture at all. Anti-anxiety medication such as Ativan (chemical name: lorazepam) can work well. Anti-acid medications such as Pepsid, Reglan (chemical name: metoclopramide), and Nexium can improve heartburn and indigestion. Making sure you're getting enough fluids can help minimize nausea. Aim for six to eight glasses of fluids a day. Avoid eating fatty foods, large meals, spicy foods, or acidic foods such as tomatoes, lemons, and oranges. Stick with bland foods—bananas, rice, unsweetened applesauce, toast, and potatoes (not fried). Medications to treat mild to moderate nausea include Torecan (chemical name: thiethylperazine), Compazine (chemical name: prochlorperazine), and Vistaril (chemical name: hydroxyzine). If you're too nauseated to take pills, you can get Compazine in suppository form. Moderate to severe nausea For moderate to severe nausea, you'll probably feel much better if you take anti-nausea medications around the clock—not just as needed. This is particularly important during the first three days that follow chemotherapy. Zofran (chemical name: ondansetron hydrochloride) is a good place to start. It's particularly good at relieving nausea associated with the chemotherapy drugs cisplatin and cyclophosphamide. Your doctor might give it to you intravenously (by vein) during chemotherapy. Afterwards, you take it every 12 hours. If you have trouble keeping it down, you can use the preparation that quickly dissolves on your tongue. If you get nauseated between the doses of Zofran, you can take a different anti-nausea medication, such as Torecan, up to every six hours. If you can't keep the Torecan down, you can try a Compazine suppository. Ativan can also be helpful medication together with a traditional anti-nausea medicine for severe nausea. Kytril (chemical name: granisetron HCI) and Anzemet (chemical name: dolasetron mesylate) are good alternatives to Zofran. Kytril is taken by pill once or twice a day. Anzemet is taken once a day. Both can also be given intravenously. For severe nausea, your doctor can give you a steroid such as Decadron (chemical name: dexamethasone) along with the anti-nausea medication. Your doctor might run the two medications intravenously, along with the chemotherapy. You don't have to worry about long-term problems of steroid use if you get steroids with your anti-nausea medications for only a couple of days. Also, to avoid or lessen severe nausea, some doctors recommend that you go into their office on the second and third day after chemotherapy for a few hours of intravenous fluids (called "IV hydration"). After the first three days beyond chemotherapy, you can usually stop taking the anti-nausea medicine around the clock. Instead, you can take it as needed, based on your doctor's instructions. If you start to experience nausea more than three days beyond chemotherapy, while you're still on anti-nausea medications, let your doctor know. In some people, these medications might not be as effective after they're taken for several days. Some of the anti-nausea medications can make you a bit sleepy or slow down your ability to react quickly. For example, if you take Ativan, you should not drive until the effects of the drug have worn off (which may take as long as eight to ten hours). None of these medications should be used right before or after drinking alcohol. Diarrhea Chemotherapy can affect all parts of your system. You can have an upset stomach that makes you queasy and nauseated, and also get cramping and diarrhea. Diarrhea can be a side effect of chemotherapy. If you have diarrhea that lasts for more than 24 hours, or if you have pain and cramping, call your doctor. Changes in your diet can help. Stick to smaller amounts of food. Avoid high-fiber foods for a while, as well as coffee, tea, or greasy or spicy foods. Drink plenty of fluids. Your doctor can prescribe medication if your diarrhea is very bad. Hair Loss Alopecia Chemotherapy may make you lose your hair completely, cause it to thin, or not affect it at all. Your doctor will be able to tell you how your specific drug will affect your hair. Your hair will begin to grow back after the treatments are over. It's not unusual for your hair to come back in a different color or texture. And remember that hair loss can occur on all parts of the body—not just the head. Sometimes it falls out right away, sometimes after a few treatments. There are no medications to prevent your hair from falling out during chemotherapy. You may want to be extra-gentle with hair while you are undergoing treatment—try using mild shampoos, soft brushes, and low heat for drying. Your doctor can write you a prescription for a wig or hairpiece, which means your insurance will probably cover at least some of the cost of buying one. Do whatever feels right to you. Want to shave your head? Do it. Wear a wig? Fine. Cover your head with colorful scarves and turbans? That's right for you. Go bald? Excellent. Just remember to use a sunscreen, hat, or scarf to protect your head from the sun. Fatigue and Anemia Many women experience fatigue after breast cancer treatment. This fatigue can range from mild to nearly debilitating. The fatigue is often the result of anemia, a condition caused when chemotherapy reduces your red blood cell count. Medications: New drugs called Epogen and Procrit will help your body increase its red blood counts, and may improve your energy levels, if your anemia improves. If you are not anemic, these drugs will not help you feel better. In addition, not everyone who takes these drugs has an improvement in red blood cell counts. Lifestyle: Get plenty of rest. If you're used to putting in twelve-hour days at work, you may have to cut back to eight (or less—listen to your body!). Enjoy some moderate exercise, which can actually help you fight off fatigue. Accept help from others for such daily activities as cleaning, shopping, or car-pooling. Know your limits. Eat a well-balanced diet. And don't try to be Superwoman. Infections Chemotherapy can increase your risk of infection. Anti-cancer drugs affect the bone marrow and decrease its ability to produce white blood cells—the very cells that fight most infections. Medications: If your white blood cell counts drop, your doctor will be able to prescribe medications such as Neupogen (chemical name: filgrastim), which works to increase your white blood cell count and reduce the risk of infection. These medications are given by injection; your doctor or nurse may teach you how to give yourself the injections. If your cell count drops too low, you and your doctor may have to consider reducing your chemo dosage for a while. Lifestyle: Wash your hands with anti-bacterial soap often during the day—especially before you eat and before and after you go to the bathroom. Stay away from people who have contagious diseases such as colds, measles, chickenpox. Stay away from children who have recently had vaccinations. Don't tear or cut your cuticles. Use lotion or oil on your skin if it becomes too dry or cracked. If you enjoy gardening, wear protective gloves. Always wear gloves if you are cleaning up after animals or small children, and always wear shoes to protect your feet. Use sanitary napkins rather than tampons to reduce the risk of infection, and use a deodorant rather than an antiperspirant for the same reasons. Sexual intercourse should always be gentle and well lubricated, to avoid small breaks in the vagina. If you think you have a fever, check with your doctor right away. Don't take any medications like aspirin or acetaminophen to reduce your fever unless you clear it with your doctor or nurse. Mouth Sores Chemotherapy can cause sores in the mouth and in the throat. These sores can easily become infected from bacteria and viruses present in the mouth. The drugs can also make mouth tissues dry or irritated and cause them to bleed. Medications: If you have mouth sores, ask you doctor for a medication to apply directly on the sores; don't use over-the-counter applications unless you check first with your doctor. Use lip balm if your lips are dry. And if you are experiencing excessive mouth dryness, ask your doctor about using artificial saliva products. Lifestyle: Get a good check-up by your dentist before you start chemotherapy. Remember that good oral hygiene and dental care are important. Use a soft toothbrush that won't hurt your gums and make them bleed. Avoid all mouthwashes that contain alcohol; these can really burn your mouth. If your mouth is tender, eat foods that are cold or at room temperature, because hot or warm foods can irritate. Drink plenty of liquids. If your mouth is really sore, eat softer foods; stay away from anything irritating or acidic that could hurt your gums and lead to mouth sores. Taste and Smell Changes Chemotherapy may cause changes in your taste and smell sensations. Foods may taste bitter or rancid, and you may develop an aversion to certain foods. Many women report that their food tastes metallic. This happens because chemotherapy alters the receptor cells in your mouth that tell your brain what flavor you are tasting or what odor you are smelling. These symptoms will continue as long as you are under treatment. Your sensations of taste and smell should return to normal several weeks after treatment has stopped. Medications: There is no medication to correct this temporary condition. However, doctors can prescribe medication to increase your appetite, if the chemotherapy has taken it away. Though some women lose weight during chemotherapy, many women report that they actually gain weight. Weight gain can result from the new medications that help control the side effects, as well as from eating more and being less active. It's important to try to maintain your normal weight during this period. Lifestyle: Avoid eating your favorite foods within a day or two after your chemotherapy, at least until you learn whether you will experience food aversions. If you have an aversion to foods that you usually rely on for most of your protein (meats, fish, eggs, and poultry), try to substitute other good protein sources (cottage cheese, peanut butter, and tofu). Chemotherapy can also affect the stomach and intestinal lining, causing you to feel "too full" after you have eaten only a few bites. Try to eat slowly, and eat frequent small meals instead of three meals a day. Avoid fatty, fried, and greasy foods, as well as gas-forming vegetables like broccoli, brussels sprouts, cucumbers, and green peppers. Menopause and Fertility During chemotherapy, your menstrual periods may become irregular or may stop altogether. If you are of childbearing age, your periods may come back once the treatment has stopped. But if you are close to menopause, your periods may never come back. That means that you will not only stop having periods, you also may not be able to conceive a child. Menopausal symptoms—the hot flashes and night sweats, vaginal dryness, and loss of interest in sex—can be difficult whether due to natural or chemically induced menopause. Some women find the loss of periods very upsetting, because it may mean that they can no longer have children. But months and sometimes years after finishing treatment, periods sometimes do return. Whether or not chemotherapy causes infertility depends on many factors, including type of drug, dosage, and a woman's age. In some cases, infertility is a temporary condition; in others, it may be permanent. Regardless, doctors advise women to use birth control throughout their treatment because chemotherapy given early on in pregnancy may cause birth defects. Chemo and Memory Loss But when the 48-year-old breast cancer survivor is asked if she would undergo chemotherapy again, she replies, "Yes. I just think it would have made a difference to know that 'chemo brain' is a real concern, just like hair loss is." Like Karen, women have long reported to their doctors that they have experienced a sense of memory loss—a feeling of being "fuzzy," "cloudy," "in a fog," or unable to concentrate like they used to—during and immediately after undergoing chemotherapy. Karen, for instance, would pay a bill—but then forget that she had paid it; invite three families for a Memorial Day picnic—but only remember inviting one; request olives for dinner—but not recall doing so when asked about it 10 minutes later. However, it's also important to remember that a number of other factors can affect a woman's memory and ability to think clearly—factors that may be significantly compromised when a woman is being treated for breast cancer. For example, a woman's ability to think clearly, remember, and concentrate can also be lessened by: Disruption of sleep. Not only do women treated for breast cancer often sleep less, but they often sleep poorly. Anxiety and a sense of uncertainty and fear may cause many women to lose sleep. In fact, the fear of breast cancer itself can keep you awake at night. Disruption of routines. Focusing on a diagnosis of breast cancer and, then on the demands of treatment and recovery, will disrupt anyone's routine. The lack of familiarity and comfort of one's daily routine can add to a woman's feeling of stress, fatigue, and anxiety. Changing hormonal patterns. For many reasons, including hormonal changes, your treatment for breast cancer may leave you feeling sad, tired, or depressed. Your treatment could also bring on an abrupt menopause years earlier than you expected, along with a rapid decline in hormone levels that can make you "feel down." You may also experience hot flashes, which disrupt your sleep. Your ability to concentrate and your memory may be compromised. Stress, anxiety, and depression. Every phase of breast cancer—diagnosis, treatment and recovery—brings with it a certain amount of stress, anxiety, and loss of control over your life. Living with the fear of recurrence can weigh you down further. The constant strain of these complex emotions can play havoc with a woman's ability to think clearly and concentrate. Other medications: steroids, hormonal (anti-estrogen) therapies, anti-depressants, sleeping pills, and pain medications can all decrease a woman's ability to concentrate. According to recent preliminary studies, chemotherapy appears to decrease mildly a woman's ability to concentrate, think clearly, and remember or recall events and details of daily life. The study that got people talking was presented in the July 2000 issue of the Journal of Clinical Oncology. It was conducted by the Department of Medical Oncology at the Princess Margaret Hospital in Toronto, Canada, in conjunction with the University of Toronto. The study involved: 31 breast cancer patients who were receiving standard doses of adjuvant chemotherapy following surgery. Some women were taking CMF (cyclophosphamide, methotrexate, and fluorouracil) and others were taking CEF (cyclophosphamide, epirubicin, and fluorouracil), both with and without tamoxifen. 40 women who had completed their chemotherapy an average of two years earlier. 36 women who never had breast cancer and never took chemotherapy. All of the women were given tests to measure any subtle abnormalities in memory, language, attention and concentration, visual-motor skills and planning skills. The results were as follows: Half of all women who were either receiving chemotherapy or who had finished chemotherapy showed mild problems with cognition and memory. Specifically, 15 of the 31 women receiving chemotherapy, and 20 of the 40 women who had finished chemotherapy, showed some loss of cognition and memory. The women currently taking chemotherapy during the study had more significant memory problems than those who had finished chemotherapy. In contrast, only 4 of the 36 women who didn't have breast cancer or receive chemotherapy showed any problems with memory or their ability to concentrate. (These women were also free from all of the other challenges that go along with a breast cancer diagnosis.) Do memory and cognition problems get better eventually? The Toronto study seems to show that memory loss does improve over time. Memory problems were not as severe among the women who had finished their chemotherapy. A more recent study from Texas, however, questioned the notion of blaming chemotherapy as the chief culprit in "chemo-brain." In this 2004 study, cognitive function was examined in women who had had biopsy, lumpectomy, and mastectomy, and then had started chemotherapy. The study looked at other possible factors, such as menopause, anxiety, and depression, and whether the women had taken hormone replacement therapy as they went through menopause. The results were not statistically significant, which means it's possible that they were due only to chance. But they did point out that memory and cognitive function could be affected by emotional distress, menopausal status, and type of surgery. This was true even in women who had not yet started chemotherapy. Many questions about memory and chemotherapy are unanswered. As more research is done, doctors hope to be able to find out how specific kinds of chemotherapy, dosage, and length of treatment affect memory and cognitive loss. Problems with Hands and Feet The taxanes (Taxol, Taxotere, and Abraxane) and Xeloda (chemical name: capecitabine) can cause discomfort or pain and numbness in the hands and feet, called neuropathy. Usually, this condition is temporary and may end after a few months. However, in certain rare cases, it can be permanent. Xeloda, prescribed for women with metastatic disease, is often given in combination with Taxotere. These medications can cause nerve damage.     The Ideal Combination for You Your ideal regimen: attacks all the different kinds of cells in the particular breast cancer you have, uses drugs that work in complementary fashion, without overlapping benefits or side effects, works in a way that is too tricky for the cancer cells to "figure out" and overcome, AND has level of side effects that's acceptable for you. After carefully reviewing the pathology of the cancer and your personal medical history, you and your doctor will decide which chemotherapy regimen, dosage, and duration is right for you. Make sure to review the risks/benefits of your choice. Think carefully about choosing what you think is "the strongest" therapy if it has the strongest side effects. Wouldn't it be wonderful if you have a good response to a regimen that DOESN'T make you feel sick? Your oncologist might choose a tried-and-true combination of drugs, with response rates ranging from 35–60%. These include AC, CMF, CAF, FAC, or AT (AT is six cycles of "A" for Adriamycin and "T" for one of the two taxane drugs, Taxotere or Taxol). Or your oncologist may choose a single agent such as Adriamycin, or either Taxotere or Taxol (with a response rate of 30–60%). Other combinations are also widely used, and may end up being the ideal chemotherapy combination for you For women with node-positive disease, a common treatment regimen is four cycles of AC, followed by four cycles of Taxol or Taxotere. Read more about different combinations of chemotherapy drugs. In women with advanced cancer, Taxotere has been found to extend survival longer than Taxol, but with more side effects. A new chemotherapy called Abraxane contains paclitaxel, the same active ingredient that's in Taxol. Abraxane is made with a protein base instead of the Cremophor base of Taxol. Cremophor, a derivative of castor oil, makes paclitaxel more toxic and can cause serious allergic reactions. But Abraxane seems to be easier to tolerate for women with metastatic disease and women don't have to be treated with steroids before taking Abraxane, as they do before taking Taxol. Myth: If you don't get sick from chemotherapy, the treatment isn't working. Fact: The "no pain, no gain" rumors about chemotherapy are just that—rumors. There is no correlation between the amount that someone suffers from chemotherapy and the benefit it has against the cancer. Everyone responds differently. Some women have very few side effects; some have them daily. Back to articles http://www.breastcancer.org/tre_sys_chemo_idx.htmlhttp://www.breastcancer.org/tre_opts_holbodsys.htmlhttp://www.breastcancer.org/tre_sys_chemo_heter.htmlhttp://www.breastcancer.org/research_chemotherapy_120002a.htmlhttp://www.breastcancer.org/research_chemotherapy_120002a.htmlhttp://www.breastcancer.org/research_chemotherapy_122003.htmlhttp://www.breastcancer.org/research_chemotherapy_122003.htmlhttp://www.breastcancer.org/tre_sys_hrt_idx.htmlhttp://www.breastcancer.org/research_chemotherapy_012606.htmlhttp://www.breastcancer.org/dia_pict_big.htmlhttp://www.breastcancer.org/dia_pict_staging.htmlhttp://www.breastcancer.org/tre_sys_hrt_idx.htmlhttp://www.breastcancer.org/tre_sys_hrt_idx.htmlhttp://www.breastcancer.org/dia_pict_cancer.htmlhttp://www.breastcancer.org/dia_pict_cancer.html#Anchor-Is-49575http://www.breastcancer.org/dia_pict_cancer.html#Anchor-Is-49575http://www.breastcancer.org/dia_pict_sizeshape.htmlhttp://www.breastcancer.org/dia_pict_cancer.html#Anchor-47857http://www.breastcancer.org/tre_sys_hrt_idx.htmlhttp://www.breastcancer.org/research_chemotherapy_120002.htmlhttp://www.breastcancer.org/research_genetics_033005.htmlhttp://www.breastcancer.org/tre_sys_tamox_idx.htmlhttp://www.breastcancer.org/research_chemotherapy_120002.htmlhttp://www.breastcancer.org/tre_sys_hrt_idx.htmlhttp://www.breastcancer.org/dia_pict_hormone.htmlhttp://www.breastcancer.org/dia_pict_hormone.htmlhttp://www.breastcancer.org/tre_sys_chemo_whatis.htmlhttp://www.breastcancer.org/tre_sys_chemo_whatis.htmlhttp://www.breastcancer.org/bone_treatment.htmlhttp://www.breastcancer.org/bone_causes.htmlhttp://www.breastcancer.org/research_chemotherapy_080001.htmlhttp://www.breastcancer.org/research_chemotherapy_080001.htmlhttp://www.breastcancer.org/rcr_metas_chemo.htmlhttp://www.breastcancer.org/research_chemotherapy_eyes.htmlhttp://www.breastcancer.org/tre_sys_chemo_nausea.htmlhttp://www.breastcancer.org/tre_sys_chemo_hairloss.htmlhttp://www.breastcancer.org/tre_sys_chemo_fatigue.htmlhttp://www.breastcancer.org/tre_sys_chemo_inf.htmlhttp://www.breastcancer.org/tre_sys_chemo_sores.htmlhttp://www.breastcancer.org/tre_sys_chemo_taste.htmlhttp://www.breastcancer.org/tre_sys_chemo_diarrhea.htmlhttp://www.breastcancer.org/index_chemo_mem.htmlhttp://www.breastcancer.org/research_hormonal_120000a.htmlhttp://www.breastcancer.org/hsn_grows_back.htmlhttp://www.breastcancer.org/hsn_wigs.htmlhttp://www.breastcancer.org/fatigue_intro.htmlhttp://www.breastcancer.org/bey_cope_meno_nTherap.htmlhttp://www.breastcancer.org/bey_cope_meno_idx.htmlhttp://www.breastcancer.org/bey_cope_meno_idx.htmlhttp://www.breastcancer.org/cmty_trans_2001_6_21.html#normal_brainhttp://www.breastcancer.org/fatigue_intro.htmlhttp://www.breastcancer.org/bey_cope_meno_Depress.htmlhttp://www.breastcancer.org/cmn_copi_fear_recur.htmlhttp://www.breastcancer.org/tre_sys_hrt_idx.htmlhttp://www.breastcancer.org/chemo_cognitive.htmlhttp://www.breastcancer.org/cmty_trans_2003_10.html#2http://www.breastcancer.org/research_chemotherapy_021706.htmlhttp://www.breastcancer.org/research_recurrence_022405.htmlhttp://www.breastcancer.org/rcr_intro.htmlhttp://www.breastcenteroftexoma.com/articles.phpshapeimage_2_link_0shapeimage_2_link_1shapeimage_2_link_2shapeimage_2_link_3shapeimage_2_link_4shapeimage_2_link_5shapeimage_2_link_6shapeimage_2_link_7shapeimage_2_link_8shapeimage_2_link_9shapeimage_2_link_10shapeimage_2_link_11shapeimage_2_link_12shapeimage_2_link_13shapeimage_2_link_14shapeimage_2_link_15shapeimage_2_link_16shapeimage_2_link_17shapeimage_2_link_18shapeimage_2_link_19shapeimage_2_link_20shapeimage_2_link_21shapeimage_2_link_22shapeimage_2_link_23shapeimage_2_link_24shapeimage_2_link_25shapeimage_2_link_26shapeimage_2_link_27shapeimage_2_link_28shapeimage_2_link_29shapeimage_2_link_30shapeimage_2_link_31shapeimage_2_link_32shapeimage_2_link_33shapeimage_2_link_34shapeimage_2_link_35shapeimage_2_link_36shapeimage_2_link_37shapeimage_2_link_38shapeimage_2_link_39shapeimage_2_link_40shapeimage_2_link_41shapeimage_2_link_42shapeimage_2_link_43shapeimage_2_link_44shapeimage_2_link_45shapeimage_2_link_46shapeimage_2_link_47shapeimage_2_link_48shapeimage_2_link_49shapeimage_2_link_50shapeimage_2_link_51shapeimage_2_link_52shapeimage_2_link_53shapeimage_2_link_54shapeimage_2_link_55shapeimage_2_link_56shapeimage_2_link_57shapeimage_2_link_58shapeimage_2_link_59