Finding the Right First-line Breast Cancer Therapy

Breast cancer is one of the most common forms of cancer. Breast cancer develops in the breast cells, and it either forms in the ducts or the lobules of the breast. Lobules are the glands in the breast that produce milk and ducts are the pathways that bring milk to the nipple from the glands. Cancer occurs in the body when mutations take place in the genes that regulate the growth of the cells. Breast cancer is treatable, depending on which stage it is at and how far inside the body it has invaded. The size of the tumor is also essential to determine what kind of treatment you need. Knowing which treatment to opt for or where to turn next in your treatment plan is a tough decision. However, understanding the different therapies that are available for you will help you make a decision that is best for you. Read on to understand more about finding the right first-line breast cancer therapy.

The most common first-line treatment for advanced hormone receptor-positive breast cancer is hormonal therapy. Advanced hormone receptor-positive breast cancer is often also referred to as progesterone receptor-positive or estrogen receptor-positive breast cancer.

Tamoxifen is generally the very first option for women who have reached menopause. If you are post-menopausal, then your doctor is likely to prescribe fulvestrant (brand name: Faslodex) or letrozole (brand name: Femara) as the first-line treatment.

There are many side effects associated with hormone therapy, and these tend to vary depending on which drug you are taking. Some of the commonly observed side effects of hormone therapy can include: ⁽¹⁾

• Joint and muscle pain
• Vaginal dryness
• Hot flashes
• Fatigue
• Nausea and vomiting
• Vaginal irritation
• Vaginal discharge

Some of the rare, but more serious side effects of hormone therapy can include:

• Osteoporosis ^{(2) (3)}
• Stroke ⁽⁴⁾
• Cataracts
• Blood clots in veins ⁽⁵⁾
• Uterine cancer or endometrial cancer
• Heart disease ⁽⁶⁾

It is believed that hormone therapies increase your risk of stroke, blood clots, and bone loss.

Targeted therapies are also used as the first-line treatment for breast cancer. There are two targeted therapies available for postmenopausal women who have advanced hormone receptor-positive/HER2-negative breast cancer. These are:

Everolimus (brand name: Afinitor): This is used along with exemestane (brand name: Aromasin). The drug is usually only reserved for use after anastrozole (brand name: Arimidex), or letrozole has been used, and these failed to control the growth of the cancer. The medication is also known to greatly increase the risk of high blood lipids and high blood sugar. Some of the common side effects of everolimus include: ⁽⁷⁾

• Cough
• Weakness or fatigue
• Shortness of breath
• Mouth sores
• Rash
• Diarrhea
• Decreased appetite

Some of the serious side effects that can be caused by Afinitor include:

• Lung and breathing problems
• Kidney failure
• Infections such as a viral or fungal infection or pneumonia
• While on Afinitor, your doctor will carry out close monitoring of your blood.

Palbociclib (brand name: Ibrance): Ibrance is generally used in combination with an aromatase inhibitor. The drug is known to increase your risk of infection. Side effects of the medication may include: ⁽⁸⁾

• Mouth sores
• Hair loss
• Nausea
• Vomiting
• Fatigue
• Diarrhea
• Neuropathy
• Anemia (low red blood cell count)
• Hair loss or hair thinning
• Decreased appetite

Some of the serious side effects associated with Ibrance include:

• Infections such as pneumonia or other types of upper respiratory infections
• Neutropenia which is a condition characterized by low white blood cell count
• Blood clots

Some of the targeted therapies that are commonly used as first-line treatment for HER2-positive breast cancer include:

• Lapatinib (brand name: Tykerb)
• Pertuzumab (brand name: Perjeta)
• Trastuzumab (brand name: Herceptin)
• Ado-trastuzumab emtansine (brand name: Kadcyla)

Some of these therapies prove to be more effective when they are used in combination with chemotherapy.

Majority of the targeted and hormonal therapies are available in pill form to be taken orally.

As there are many side effects of both these treatments, your doctor will be monitoring your condition closely. However, if your cancer continues to progress while you are on either of these therapies or if the side effects start becoming overwhelming, then your doctor will change your medication. If even after changing your prescription, cancer still continues to progress, then you might have to switch to chemotherapy alone.

Chemotherapy is one of the most common first-line treatment for breast cancer. The drugs used in chemotherapy are designed to kill the fast-growing cells, which is why this is a very effective treatment for destroying cancer. However, since the therapy kills fast-growing cells in the body, in the process, there will be other fast-growing cells in the body that can also get damaged. These may include:

• Cells in your reproductive system
• Cells in your mouth
• Cells in your digestive tract
• Cells in the bone marrow that help produce blood
• Hair follicles

Many chemotherapy drugs are also known to cause serious damage to your heart, lungs, bladder, and the nervous system.

There are many possible side effects of chemotherapy, and while some people only experience a couple of these, others tend to go through more. Side effects of chemotherapy can range from being mild to severe and include the following: ⁽⁹⁾

• Loss of appetite
• Nausea
• Vomiting
• Diarrhea or constipation
• Numbness and tingling
• Hair loss
• Fatigue
• Mood changes
• Weight loss
• Changes to your fingernails and toenails
• High risk of infection
• Easy bruising and bleeding
• Anemia (low count of red blood cells)
• Throat problems such as sores and pain in swallowing
• Skin and nail changes including dry skin and color change
• Kidney damage
• Changes in sexual function and libido
• Fertility problems
• Chemo brain – a condition which affects your concentration and focus

It is possible to minimize some of these side effects with other medications, but still, chemotherapy will leave you susceptible to many different illnesses and infections.
The chemotherapy drugs are administered intravenously during specific intervals. This could be a weekly or every two-week schedule. Each chemo session is known to last for several hours, so plan your day accordingly is very important. You will find that the side effects are usually much more severe during the first couple of days after the treatment.

There are many different types of chemotherapy drugs that are prescribed in various combinations, and if your cancer stops responding to a particular drug, your oncologist will try out a different medication or a different drug combination to see which works better for your condition.

Chemotherapy is the primary treatment for a type of breast cancer known as hormone receptor-negative. However, this is not to say that it cannot be used in other types of breast cancer.

In many cases, chemotherapy is the only first-line treatment for certain breast cancers. For example, when breast cancer tests progesterone receptor-negative, estrogen receptor-negative, and HER2-negative, it is known as triple-negative breast cancer, and there is no other hormonal or targeted therapies that can help in such type of cancer. ⁽¹⁰⁾ This is why chemotherapy is used as the first-line treatment in such rare cases.

Another type of targeted therapy that is also used as first-line treatment for certain types of breast cancers. Radiation therapy helps destroy cancer cells in one particular area and is helpful in the treatment of metastases in a specific area. It helps in relieving pain and other symptoms of breast cancer. However, if you have previously had radiation therapy in the same area, then it cannot be repeated.

Radiation is usually used in metastatic or stage IV breast cancer for the treatment of:

• Bleeding problems
• Spinal cord compression that happens due to a tumor
• Tumors growing in the brain
• Cancer in the bones
• Pain related to tumors in the liver

Your doctor will administer radiation therapy typically every day for several weeks. It is a painless process, but it can still cause some temporary side effects such as irritation on the skin and fatigue.

There are many types of treatments for breast cancer. Chemotherapy, hormone therapy, targeted therapy, and radiation therapy are just some of the first-line therapies that are used either alone or in combination.

You will continue on these treatments as long as the cancer does not progress, and the side effects do not become overwhelming. Once the procedure is no longer effective or the side effects become too much to handle, your doctor will then proceed to trying other therapies. Clinical trials are also an option, and you can discuss with your doctor to see if there are any clinical trials for your condition.

Always discuss the pros and cons of each treatment option with your doctor and be frank about how you will be able to adjust the treatment into your lifestyle and manage your life to give the required time to these treatments.

References

1. Cancerresearchuk.org. (2019). Side effects of hormone therapy | Cancer Research UK. [online] Available at: https://www.cancerresearchuk.org/about-cancer/cancer-in-general/treatment/hormone-therapy/side-effects-women [Accessed 19 Aug. 2019].
2. Cancerresearchuk.org. (2019). Osteoporosis risk and hormone therapy | Cancer in general | Cancer Research UK. [online] Available at: https://www.cancerresearchuk.org/about-cancer/cancer-in-general/treatment/hormone-therapy/osteoporosis [Accessed 19 Aug. 2019].
3. Ramaswamy, B. and Shapiro, C.L., 2003, December. Osteopenia and osteoporosis in women with breast cancer. In Seminars in oncology (Vol. 30, No. 6, pp. 763-775). WB Saunders.
4. Henderson, V.W. and Lobo, R.A., 2012. Hormone therapy and the risk of stroke: perspectives 10 years after the Women’s Health Initiative trials. Climacteric, 15(3), pp.229-234.
5. Breast Cancer Care. (2019). Blood clots. [online] Available at: https://www.breastcancercare.org.uk/information-support/facing-breast-cancer/going-through-treatment-breast-cancer/side-effects/blood-clots#Breast%20cancer%20treatments%20that%20increase%20the%20risk%20of%20blood%20clots [Accessed 19 Aug. 2019].
6. ScienceDaily. (2019). Breast cancer treatments may increase the risk of heart disease: American Heart Association scientific statement. [online] Available at: https://www.sciencedaily.com/releases/2018/02/180201085812.htm [Accessed 19 Aug. 2019].
7. Breastcancer.org. (2019). Afinitor (Everolimus): Side Effects, How it Works, and More. [online] Available at: https://www.breastcancer.org/treatment/targeted_therapies/afinitor [Accessed 19 Aug. 2019].
8. Breastcancer.org. (2019). Ibrance (Palbociclib): Side Effects, How it Works, and More. [online] Available at: https://www.breastcancer.org/treatment/targeted_therapies/ibrance [Accessed 19 Aug. 2019].
9. Cancer.org. (2019). Chemotherapy Side Effects. [online] Available at: https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/chemotherapy/chemotherapy-side-effects.html [Accessed 19 Aug. 2019].
10. Breastcancer.org. (2019). Triple-Negative Breast Cancer: Overview, Treatment, and More. [online] Available at: https://www.breastcancer.org/symptoms/diagnosis/trip_neg [Accessed 19 Aug. 2019].

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