The aim of chemotherapy for metastatic breast cancer is to stop the cancer from growing or spreading, to relieve symptoms and improve quality of life. For some people, chemotherapy can make the cancer smaller. The benefits of treatment with chemotherapy can last for some time – sometimes for years.
How does chemotherapy work?
Chemotherapy works by killing cells that are rapidly dividing, such as cancer cells.
As well as killing cancer cells, chemotherapy also kills normal cells that are rapidly dividing. However, unlike cancer cells, normal cells can repair the damage and can recover.
The main areas of the body that are affected by chemotherapy are the mouth, stomach and bowel (gut), skin, hair and bone marrow. Damage to these normal cells causes the side effects of chemotherapy.
Types of chemotherapy
The chemotherapy drugs recommended will depend on what other treatments the woman is receiving, the type, stage and grade of breast cancer and the woman’s age.
Chemotherapy drugs are grouped based on how they work. The main groups, or classes, of chemotherapy used to treat breast cancer are:
- anthracyclines such as epirubicin (Pharmorubicin®), doxorubicin (Adriamycin®)
- mitotic inhibitors such as taxanes, eg paclitaxel (Taxol®), docetaxel (Taxotere®)
- antimetabolites such as 5-fluorouracil (5FU), capecitabine, 5-fluorouracil (5-FU), gemcitabine (Gemzar®)
- alkylating agents such as cyclophosphamide
- taxanes such as paclitaxel (Taxol®), docetaxel (Taxotere®)
- vinorelbine (Navelbine®)
- targeted therapies such as trastuzumab (Herceptin®), lapatinib (Tykerb®), bevacizumab (Avastin®).
Each group of chemotherapy drugs works in a slightly different way. All of them kill cancer cells by stopping them from dividing or damaging them in some way.
Combinations of chemotherapy are often referred to using the initials of the drugs being used. For example, FEC chemotherapy is a combination of 5- fluorouracil, epirubicin and cyclophosphamide.
What does chemotherapy involve?
Before starting treatment, the woman will meet with a medical oncologist to discuss which types of chemotherapy are recommended and the side effects of these treatments.
The most common way to give chemotherapy is by injection into a vein. This is called intravenous chemotherapy. The drugs are given using a ‘drip’, usually into the hand or arm. Some chemotherapy drugs are given as a tablet (oral chemotherapy). Some women have a combination of tablets and intravenous chemotherapy.
Sometimes it can be difficult to find a suitable vein to give chemotherapy into. If this happens there’s the option of having a long-term access device (infusaport or Portacath®) or a PICC line (peripherally inserted central catheter). This involves putting a thin, soft plastic tube into a vein into the chest or arm that can be left in for weeks or months. The tube can be used to deliver chemotherapy. Sometimes, the tube connects to a disc (the ‘port’) under the skin of the chest.
Chemotherapy is usually given in a clinic or hospital on an outpatient basis by a chemotherapy nurse. It may be given in a room or ward with other people who are receiving chemotherapy.
Chemotherapy cycles
Chemotherapy is usually given in ‘cycles’. Each cycle involves a short period of treatment followed by a rest period. This gives the body a chance to recover between treatments. The number of cycles, the length of the treatment period and the length of the rest period will depend on the stage and grade of breast cancer and the type of chemotherapy.
Side effects
Because the drugs all work differently, they have different side effects. Chemotherapy drugs can also affect individual women in different ways. Most side effects of chemotherapy can be managed with medical care.
Some of the possible side effects of chemotherapy are listed below. It’s unlikely that a woman will have many or all of these side effects. It’s also important to remember that having chemotherapy can have great benefits.
It’s possible to have chemotherapy with very few side effects. If this happens, it doesn’t mean that the chemotherapy is not working.
Common side effects of chemotherapy include:
- nausea and vomiting
- fatigue (tiredness)
- hair loss
- diarrhoea or constipation
- weight gain or weight loss
- mouth ulcers and infections
- skin or nail changes or reactions
- menopausal symptoms (temporary or permanent)
- depression or anxiety
- sexual difficulties
- nerve and muscle problems
- swelling in the arms and legs
Less common side effects of chemotherapy include:
The following side effects of chemotherapy are rare but can be quite serious (medical advice should be sought if any of the following occur):
- infection due to a low level of white blood cells
- bleeding or bruising
- kidney or bladder problems
- heart problems
- bone marrow problems
- allergic reactions.
Nausea and vomiting
Nausea (‘feeling sick’) and vomiting are common side effects of chemotherapy. These symptoms are less common with chemotherapy programs that involve taxanes. Some women are nervous or worried before their next cycle of treatment and this can make them feel sick or vomit. This is called anticipatory vomiting.
What can help with nausea and vomiting?
Nausea and vomiting can usually be controlled using drugs called anti-emetics. Anti-emetics are usually given at the same time as chemotherapy. Effective treatments are available for anticipatory vomiting, such as relaxation training. It can be helpful to eat smaller meals more often rather than larger meals while having chemotherapy.
Nausea and vomiting can usually be controlled using drugs called anti-emetics. Anti-emetics are usually given at the same time as chemotherapy. Effective treatments are available for anticipatory vomiting, such as relaxation training. It can be helpful to eat smaller meals more often rather than larger meals while having chemotherapy.
Fatigue
Feeling tired is a common side effect of chemotherapy and can last 3–6 months after treatment is over. Fatigue can also be due to anaemia caused by chemotherapy. Blood tests are used during chemotherapy so that doctors can check the woman’s blood cell count. A red blood cell transfusion may be recommended if significant anaemia develops.
What can help with fatigue?
It can be useful to organise practical help before starting treatment, for example, help with childcare or making meals.
A normal reaction to feeling tired is to rest. However, exercising during and after treatment can help women feel less tired. It can also reduce the chance of weight gain. Exercise has also been shown to help improve sleep, body image and mood. Gentle exercise like walking is ideal. Some women find that more strenuous exercise is also helpful.
Hair loss
Not all chemotherapy drugs cause hair loss. However, the drugs most frequently used to treat early breast cancer are likely to cause hair loss. Hair loss is more common with chemotherapy programs that include anthracyclines and taxanes.
Hair loss from chemotherapy can range from mild thinning of the hair to total hair loss, including body hair. When the hair grows back it may be more curly, thicker or finer than it was before treatment. It may grow back a slightly different colour.
Although losing hair loss may not seem serious compared with coping with breast cancer, many women find it upsetting. Hair loss may affect how a woman feels about herself and her sexuality.
Coping with hair loss
Some women find it helpful to cut their hair short if they’re having chemotherapy so that it’s less upsetting if their hair does fall out. Many women choose to wear a scarf, hat or wig to cover the head while the hair grows back.
Look Good Feel Better workshops are available at locations around Australia. These are free of charge and provide tips and advice about dealing with appearance-related side effects of chemotherapy. Workshops are available in capital cities and other major centres.
Diarrhoea and constipation
Some women experience diarrhoea or constipation during chemotherapy. Constipation can be caused by chemotherapy and some anti-emetic drugs, or it can develop because women are less active or eat less during treatment.
What can help with diarrhoea and constipation?
Medication can be used to control symptoms of diarrhoea and constipation. Constipation can be treated by drinking more fluids, eating more fruit and vegetables, and using laxatives. Exercise can also be helpful in reducing constipation.
Weight gain or weight loss
Some women lose their appetite during chemotherapy and lose weight. Other women find that they put on weight during treatment.
What can help with weight gain/loss?
Eating small meals and snacks as often possible throughout the day can help prevent weight loss during treatment. Doing gentle exercise can help prevent weight gain during chemotherapy.
Mouth ulcers and infections
Some women receiving chemotherapy get mouth ulcers. Mouth ulcers usually occur about 5–10 days after starting chemotherapy and clear up within 1–2 weeks. Sometimes chemotherapy can cause other mouth infections in mouth, such as thrush or cold sores.
What can help with mouth ulcers and infections?
It’s important to take extra care of the mouth during chemotherapy.
Things that can help if mouth ulcers develop include:
- brush the teeth and gums with a very soft brush after every meal to prevent infection
- use an analgesic gel from the chemist or sodium bicarbonate mouthwash to help relieve discomfort
- pain relief such as paracetamol may be helpful.
Some mouthwashes can make ulcers worse – advice should be sought from a health professional before using a mouth wash. Treatments are available from a doctor or pharmacist for mouth infections such as thrush.
Skin and nail problems
Some women have minor skin or nail problems while they are having chemotherapy. These include redness, itching, peeling, dryness or acne. Some women’s nails become darker, brittle or cracked. Some chemotherapy drugs can make the skin more sensitive to the sun.
Most skin and nail problems are not serious. However, a sudden rash, sudden or severe itching, or breathing difficulties could be symptoms of a severe allergic reaction that requires treatment. Medical assistance should be sought immediately from a doctor or hospital emergency department.
Hand–foot syndrome can be a side effect of chemotherapy that includes capecitabine or liposomal doxorubicin (Caelyx®) (used to treat metastatic breast cancer). The skin of the hands or feet can become red, swollen, cracked or painful. For many women, symptoms are mild and do not interfere with daily activities. However, for some women, the symptoms can be very painful and can make it difficult to walk or use the hands.
What can help with skin and nail problems?
It’s recommended that women having drugs that affect the skin and nails avoid being in the sun for long periods, and use sunscreen when outdoors. Health professionals can provide advice about managing skin and nail problems caused by chemotherapy and about moisturisers that can be used to manage hand-foot syndrome.
Menopausal symptoms and permanent menopause
About two-thirds of women who are younger than 50 when their breast cancer is diagnosed will go through menopause because of their treatment. Other women may experience temporary menopausal symptoms. The closer a woman is to the age of natural menopause, the more likely it is that menopause will be permanent. Find out more about menopause and breast cancer.
If menopause is permanent, it’s not possible to have children naturally after treatment. Women who have not yet reached menopause and hope to have children in the future should talk to a fertility specialist before making treatment decisions and starting treatment.
Find out more
Depression and anxiety
Some women feel depressed, sad or teary before, during and after chemotherapy. Others feel anxious, worried, nervous or upset. Some feelings of sadness, depression and anxiety are normal.
What can help with depression and anxiety?
Treatments are available for women experiencing feelings or emotions that are interfering with things at home, or affecting relationships.
Find out more
Sexual difficulties
Many women have some sexual difficulties during chemotherapy treatment. This can be because of feeling unwell or because of the effects of treatment on the body. Some women experience these feelings for a while after treatment is over.
Find out more
Nerve and muscle problems
Some chemotherapy drugs can cause nerve and muscle problems during treatment. Severe problems are uncommon. More common symptoms include tingling, burning or numbness in the hands or feet. Some women have problems with balance or have weak or sore muscles for a few days after chemotherapy. These symptoms are more common with taxane drugs.
Treatment can be adjusted for women experiencing nerve or muscle problems.
Swelling in the arms and legs
Swelling or fluid retention may occur, particularly in the arms and/or legs. Swelling is most common in the feet and ankles due to the effects of gravity. This side effect is most common with the use of some taxane chemotherapy drugs.
Arm and leg swelling caused by chemotherapy is not the same as lymphoedema and rarely requires any specific treatment. However, treatment may be prescribed if the swelling is severe.
The risk of arm or leg swelling can be reduced by giving another medication before chemotherapy. Symptoms will slowly improve once treatment is over.
Feeling vague or ‘in a fog’
Some women feel ‘vague’ or mildly confused or have memory problems while having chemotherapy. This is sometimes called ‘chemo brain’ or ‘chemo fog’. Symptoms can last for some months after treatment is over.
The causes of these feelings are being studied.
Infection
Chemotherapy drugs reduce the number of white blood cells produced by the body. The white blood cell count will be checked regularly during chemotherapy. If the white blood cell count drops, this will usually happen 1–2 weeks after treatment.
Women with a low white blood cell count may be at increased risk of developing an infection. The risk of infection is highest for people who have drugs called taxanes at the same time as anthracyclines. A drug called a growth factor (G-CSF) may be given after each chemotherapy treatment to lower the risk of infection.
Signs of a severe, life-threatening infection may include:
- fever (a temperature higher than 38ºC)
- chills
- severe sweats.
If these symptoms develop, immediate medical advice should be sought as treatment with strong antibiotics may be required.
Other symptoms of infection include:
- loose bowels
- a burning sensation during urination
- severe cough or sore throat
- unusual vaginal discharge or itching
- redness, swelling or tenderness around a wound, sore, pimple, boil, or the site where the chemotherapy drip was inserted.
Infections during chemotherapy can be treated effectively with antibiotics.
Bleeding or bruising (rare)
In rare cases, chemotherapy can make a woman bleed or bruise more easily. This is because chemotherapy can affect cells in the blood called platelets. The platelet count will be checked during chemotherapy.
If chemotherapy affects the platelets, this will usually happen 1–2 weeks after treatment.
Symptoms to look out for include:
- easy bruising
- bleeding from gums or nose
- reddish urine
- black or bloody bowel motions (stools).
These symptoms should be reported to a health professional as soon as possible.
Unusual bruising or bleeding can be treated by a platelet transfusion.
Kidney and bladder problems (rare)
Some chemotherapy drugs can irritate the bladder or cause damage to the kidneys. In very rare cases, this damage can be permanent. If kidney or bladder problems do develop, they will usually happen a few days or more after chemotherapy treatment.
Symptoms to look out for include:
- pain or burning during urination
- frequent urination
- feeling the need to urinate right away
- reddish or bloody urine
- fever or chills.
These symptoms should be reported to a health professional as soon as possible.
With some chemotherapy drugs, it’s normal to have reddish urine for 24 hours after treatment. Reddish urine caused by an infection in the bladder or kidneys usually develops a few days or more after treatment.
Drinking plenty of fluid can help prevent kidney and bladder problems.
Other rare/uncommon side effects of chemotherapy
Other rare side effects of chemotherapy include:
- heart problems (cardiac toxicity) – with anthracyclines
- problems with bone marrow – most commonly with anthracyclines
- allergic reactions – with taxanes.
If these side effects develop during treatment the chemotherapy drugs will be changed, or the dose decreased. Drugs can be given before chemotherapy to lower the chance of an allergic reaction.
Find out more
Questions to ask
Listed below are some questions that might be useful to ask when talking about chemotherapy:
- How will chemotherapy benefit me?
- Which chemotherapy drug(s) do you recommend for me? Why?
- If I have chemotherapy, when will it start?
- If I have chemotherapy, how will it be given and for how long?
- Will I need tests while I'm having chemotherapy? When?
- How much will the chemotherapy cost?
- What are the side effects of the drugs you are recommending?
- How can I manage side effects if they develop?
- Are the side effects permanent or temporary?
- Who should I contact if I have side effects or other problems?
- Is there an out-of-hours phone number I can call if I develop serious side effects during the night or on weekends?
- Will chemotherapy affect my ability to have children?
- What do I need to consider when deciding whether or not to work while having chemotherapy?
- If I’m taking complementary therapies, how will they affect the chemotherapy?
- What exercises do you recommend while I’m having chemotherapy?
- What sort of food should I eat while I have chemotherapy?
