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Chemotherapy and/or radiation therapy are two types of treatment commonly given to breast-cancer patients in addition to surgery. The surgery physically removes the tumor, while the chemo and radiation kill off stray cancer cells that may still be lurking in the area or have traveled through the lymphatic system to other parts of the body. If you have picked up this book, then not only are you preparing for chemo and/or radiation treatments, but you are also exhibiting extraordinary literary taste, and for that I congratulate you.
Getting chemo isn't a walk in the park, but on the scale of things that make me nauseous, it still beats a tax audit. There are fabulous new designer drugs available to help you get through chemo (some patients don't ever throw up!), whereas if you are audited, very few drugs will alleviate your pain.
Science is making breakthroughs every day in treating cancer, breast cancer in particular. When caught in the early stages, it is so treatable it's considered curable. Meanwhile, chemo and radiation (in addition to surgery and synthetic hormones such as tamoxifen) are the best weapons in the modern world's breast cancer arsenal.
Yet it all sounds so frightening. Radiation seems scary because if you didn't pay attention back in science class, then you haven't the foggiest idea of how and why it works. Chemo, on the other hand, is not such a mystery. Everyone has an opinion on chemo, and it's usually not a good one. The prospect of going through chemo can be more troublesome to many people than the cancer itself. When the surgeon who performed my lumpectomy told me that I'd need chemo, I blanched and said this was the first I'd heard of it, when in fact we had discussed it a mere two days before. I had blocked the memory of that discussion entirely and was in such denial that I thought my surgeon was pulling a fast one.
A BRIEF HISTORY OF BREAST CANCER-OR, BE THANKFUL YOU WEREN'T BORN WAY BACK WHEN
Boy, are you lucky, all things considered. It wasn't until the sixteenth century that anatomy became a science, so surgery before that time was largely based on folk wisdom. Be grateful you were not born before the mid-nineteenth century, when anesthetics and antiseptics were first discovered. Until then, a patient was lucky to get a shot of whiskey before being cut open.
If you think chemo sounds bad, at least it's proven to be effective, unlike the treatments of yore. It would not be wise to get breast cancer in France in 1350, where you might be prescribed "an infusion of elderberry roots pickled in vinegar for nine days." Marilyn Yalom, in her book A History of the Breast, lists just a few of the horrible mixtures smeared on breasts in the name of medicine in ages past, including burned excrement of men, wasps, or bats; cow's brain; crawfish boiled in ass's milk; pork blood, arsenic, lead, and mercury ointments; compresses dipped in urine; rotten apples; and vivisected pigeon parts.
The first surgeon to add axillary dissection to breast surgery (removal of lymph nodes under the arm), even before the lymphatic system was discovered, was the German surgeon Wilhelm Fabry at the turn of the seventeenth century, when it was still thought that breast cancer was caused by breast milk that had curdled and hardened. "For the next 200 years, medicine and quackery, superstition and science, unfounded prejudice and empirical observation coexisted willy-nilly, as they still do, if less flagrantly, in our own time," writes Yalom. Her descriptions of old-time folk remedies are reminiscent of some of today's superstitions, such as trying to cure cancer with herbal tea or positive thinking.
Chemo, by comparison, has the clear advantage of being effective in a predictable percentage of cases, a percentage clearly higher than would be the case if you did nothing. It was initially used as an adjuvant treatment in the 1960s. You can see why chemo got such a bad rap. Before better antiemetic drugs were discovered to prevent nausea, many patients spent the better part of their time camped out in their bathrooms. The fear of treatment-of the time it takes, the hassle, the laundry list of possible side effects-can feel more devastating than the treatment itself.
I'm a firm believer in the adage knowledge is power. The more you know about why and how these treatments work and what to expect, the better you will be able to cope with them and be a proactive patient who participates in her own recovery. (Only 1 percent of breast-cancer patients are men, so guys, if you're reading this, you'll just have to put up with the feminine pronoun throughout this book.)
I'm not recommending that you go overboard and get a doctoral degree in oncology. I'm just saying that a lot of the fear of cancer treatments has to do with fear of the unknown.
So let's demystify the process!
The most famous midwife in Paris during the early 1600s was Madame Louise Bourgeois, who brought Louis XIII into the world. Here is Madame's Rx for breast cancer, according to A History of the Breast: "Take a half-pound of lard and dissolve it, a small amount of new wax, two ounces of pitch [tar], and from all of this make an ointment, with which you will plaster the breast once it has been lanced."
For many breast cancer patients, chemo is the next step after surgery. Chemo and radiation are both very intensive and their cumulative impact makes you tired, so doctors typically administer them separately. One advantage of leaving radiation for last is that it gives your breast more time to heal after surgery, but the order in which you receive the two may be a function of the policy of your hospital, or whether your cancer is estrogen-receptor positive. In some cases, chemo is given even before surgery to reduce the size of the tumor.
Chemo is a "systemic" treatment (because it travels throughout your system) that is administered either in pill form or through an IV (intravenous needle). There are different kinds of chemo and different chemo combinations, or "cocktails." What they basically do is kill off fast-growing cells by interfering with the rogue cells' ability to divide. Cancer cells are fast-growing cells; unlike my own mathematical abilities, they divide and multiply with lightning speed. Eventually, they crowd out the normal cells, preventing the body from performing its necessary functions. Chemo singles out fast-growing cells and says to them, "Can't you read the sign? This is a no-dividing, no-multiplying zone! Move along!"
However, the chemo cannot differentiate between the "bad" fast-growing cells and the "good" fast-growing cells, which happen to be the ones in the digestive tract, the reproductive organs, the bone marrow (where new blood cells are manufactured), and the hair follicles. This explains some of chemo's famous side effects, like runny nose, upset stomach, low blood counts, and hair loss. The amount or type of side effects you get are not an indication of how and whether the chemo is working, but of how your body happens to respond under the circumstances.
Chemo is administered (generally on an out-patient basis) in "cycles," meaning that the body gets to recover a bit (usually three or four weeks) before the next infusion. Shorter cycles are now possible using new bone marrow stimulants, but these are not considered standard at present. Four doses, then, would typically take about three months.
Like all cells, cancer cells go through growth phases. The exact effect of various chemotherapy agents is not always the same and the mechanisms by which they kill cells is not necessarily known. In general, scientists think chemo attacks cancer cells before they are able to divide. Since different cells are at different growth phases at different times, the chemo kills off cancer cells in waves, then hits others during the next round of treatments, etc. The first blast of chemo wipes out as many cancer cells as possible. After that, the chemo continues to "stalk malignant cells," as one book describes the process, which brings to mind chemo molecules in hunting caps and red-plaid jackets. In fact, scientists believe that the same proportion of cells are killed with each dose. However, this presents a problem similar to the man who halves the distance home with each step-he never actually gets there!
In addition, cells may grow back after each treatment. The hope is that enough cycles of effective treatment will kill enough cancer cells to allow other bodily defenses to limit growth of cancer cells.
In addition to being "systemic," chemo is also called an "adjuvant" treatment for breast cancer because it is administered in addition to surgery. (Radiation, however, is considered a "primary" treatment, and is almost always given to women who have had lumpectomies, and occasionally to women who have had mastectomies.)
The key motivation for the use of chemotherapy (and hormone therapy, too) is that, unlike surgery and radiation treatments which are aimed at identified sites of cancer, chemo is unaimed and can attack cancer wherever it might be lurking in the body.
Years ago, it was assumed that if few or no lymph nodes were involved (diagnosed "positive"), then the cancer hadn't spread to any other parts of the body. The lymph nodes were considered the tollbooths on the cancer highway, and if they hadn't seen any traffic yet, it was assumed you were relatively safe.
Later it was found that cancer cells could break away at any time and wander past your internal "no trespassing" signs, even when a tumor was in its early stages. These stray cancer cells, while invisible to imaging methods like X rays, could set up shop elsewhere, most notably in the liver or bones, thus metastasizing (or spreading) the original cancer to other parts of the body. When this happens, the far-flung cancer is still known as "breast cancer," no matter where in the body it shows up.
Because of these discoveries, today's breast cancer patients very often get chemo if only as an insurance policy, just in case a cell or two escaped and is on the lam.
Chemo Cocktails: Recipe for Health
There are dozens of chemotherapy drugs available to fight cancer. Here is a list of the most common chemo "cocktails," or combinations, given to breast cancer patients. Granted, they are not as appealing as such cocktails as the chocolate martini.
CMF: Cyclophosphamide (marketed as Cytoxan), methotrexate, 5-fluorouracil (5-FU)
CAF: Cyclophosphamide, doxorubicin (Adriamycin), 5-fluorouracil
CEF: Cyclophosphamide, epirubicin, 5-fluorouracil
CMFVP: Cyclophosphamide, methotrexate, 5-fluorouracil, vincristine, prednisone
AC: Doxorubicin, cyclophosphamide
VAT: Vinblastine, doxorubicin, thiotepa
VATH: Vinblastine, doxorubicin, thiotepa, fluoxymesterone
CDDP + VP-16: Cisplatin, etoposide, mitomycin C plus vinblastine
AC + T: Doxorubicin and cyclophosphamide followed by paclitaxel
AC + Txt: Doxorubicin and cyclophosphamide followed by docetaxel
Chemo is often administered in cocktails because it has been found that these combinations are far more effective than using any of the agents singly. However, even that conclusion is currently under very careful study. As noted in the doctors' reference book Principles of Cancer Management: Chemotherapy, "Although such selection leads to a wider range of side effects, it minimizes the risk of a lethal effect caused by multiple insults to the same organ system by different drugs and allows dose intensity to be maximized."
My own chemo regimen involved three months of Adriamycin and six months of CMF, the latter of which I dubbed "chemo lite" because it allowed my hair to grow back.
"Adria" was the chemo I liked least. The name sounded so pretty and it came in a cheerful orange color, but it is quite potent and needs to be administered with plenty of IV fluids so that it doesn't sclerose (scar) the vein. It's also part of the chemo family that, at typical doses, is guaranteed to make you lose your hair-other types may just thin it. Your doctor will custom tailor your chemo regimen based on a number of factors. Some of these factors have to do with your original tumor, such as how large it was or whether any lymph nodes under the arm were involved. The type and amount of chemo you get is also dependent on your age and general health. The oncologist will factor in risk versus reward when designing the length and aggressiveness of your treatment. If you've lived a long, full life, you may not want to spend a precious six months undergoing chemo.
How much chemo you can tolerate is initially formulated according to the measurement of your body surface and later refined as treatments progress. Your doctor will know how well it's working not by how many side effects you get, but by the measurable evidence in your blood counts.
Questions to ask your Oncologist
How many patients have you treated with similar cases?
Why do I need this treatment?
How long will this treatment take?
What is my prognosis? (This is a tricky question, because the oncologist needs to be frank without unduly alarming you. Still, you have a right to know what he thinks about your particular case, and how other women fared with similar treatments. Just keep in mind that an answer to this question is only an estimate based on comparison with huge swaths of the population.)
What are my options regarding chemo, and do I have other options besides chemo?
Why are you recommending this particular chemo regimen? (Most chemo regimens are standard, the difference being in the amount an individual receives. But the doctor may have a philosophy about treatment that you'll be interested to hear.)
What are the possible side effects, and when do they show up? Who do I call to help me manage the side effects? The oncologist? A nurse? A resident on duty at the hospital if it's after 5 p.m.?
Excerpted from Breast Cancer, There and Back by Jami Bernard Copyright © 2001 by Jami Bernard. Excerpted by permission.
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Posted December 28, 2009
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