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Which First-Line Breast Cancer Therapy Is Right for Me?

Medically reviewed by Christina Chun, MPH on March 22, 2017Written by Ann Pietrangelo on March 22, 2017
breast cancer

Knowing where to turn next with your breast cancer treatment can be a tough decision. But understanding the different types of therapies can help ensure you know what’s best for you.

Hormone and targeted therapies

The first-line treatment for advanced hormone receptor-positive (estrogen receptor-positive or progesterone receptor-positive) breast cancer is usually hormone therapy.

Tamoxifen is generally the first option for premenopausal women. If you’re post-menopausal, you’ll likely try letrozole (Femara) or fulvestrant (Faslodex) first.

Side effects of hormone therapy vary with each drug, but can include:

  • hot flashes and night sweats
  • vaginal dryness
  • loss of sex drive
  • mood swings

Hormone therapies can also increase your risk of blood clots, stroke, and bone loss.

Two targeted therapies for postmenopausal women with advanced hormone receptor-positive/HER2-negative breast cancer are:

  • Palbociclib (Ibrance), which is used in combination with an aromatase inhibitor. Side effects may include nausea, mouth sores, hair loss, fatigue, and diarrhea. This medication may raise your risk for infection.
  • Everolimus (Afinitor), which is used in combination with exemestane (Aromasin). It’s generally reserved for use after letrozole or anastrozole (Arimidex) have failed to control the cancer. Side effects can include shortness of breath, cough, and weakness. This medication can increase the risks of infection, high blood lipids, and high blood sugar. Careful monitoring of the blood is necessary.

Targeted therapies for HER2-positive breast cancer include:

  • trastuzumab (Herceptin)
  • pertuzumab (Perjeta)
  • ado-trastuzumab emtansine (Kadcyla)
  • lapatinib (Tykerb)

Some of these may be more effective when used in combination with chemotherapy.

Most hormonal and targeted therapies are available in pill form.

If side effects get overwhelming, or your cancer continues to progress while taking hormonal or targeted therapy, changing drugs is a good strategy. If you’ve already done that and cancer is still progressing, you may have to switch to chemotherapy alone.

Chemotherapy

Chemotherapy drugs are designed to kill fast-growing cells, which is why they’re so effective in destroying cancer. But there are other fast-growing cells in your body that can be damaged in the process, including:

  • hair follicles
  • cells in your bone marrow that help form blood
  • cells in your mouth, digestive tract, and reproductive system

Some chemotherapy drugs can damage your nervous system, bladder, kidneys, lungs, or heart.

Chemotherapy has many potential side effects. Some people only experience a few, while others go through more. Symptoms range from mild to severe and can include:

  • hair loss
  • loss of appetite
  • nausea and vomiting
  • diarrhea or constipation
  • numbness and tingling
  • changes to fingernails and toenails
  • fatigue
  • weight loss
  • mood changes

Some side effects can be minimized with other medicines.

Chemotherapy can also leave you more vulnerable to illness and infection.

The drugs are administered intravenously at certain intervals, which could be weekly or every two weeks, for example. Each session may last several hours. Side effects are usually more severe in the first few days after treatment.

There are many different chemotherapy drugs that can be used in various combinations. If your cancer stops responding, your oncologist can try a different drug or drug combination.

Chemotherapy is the main treatment for hormone receptor-negative breast cancers. It can also be used for other types of breast cancer.

When breast cancer tests estrogen receptor-negative, progesterone receptor-negative, and HER2-negative, it’s called triple-negative breast cancer. There are no hormonal or targeted therapies for this type, so chemotherapy would be the first-line treatment.

Radiation therapy

Radiation is a type of targeted therapy that can destroy cancer cells in a specific area.

Radiation therapy may be helpful in treating metastases in a particular area with the goal of easing pain and other symptoms. However, it can’t be repeated if you have previously had radiation to the same area.

In metastatic breast cancer, radiation is usually used to treat:

  • spinal cord compression due to a tumor
  • tumors in your brain
  • cancer in your bones
  • bleeding problems
  • pain due to tumors in your liver

Radiation therapy is usually administered every day for several weeks.

It’s a painless procedure but can cause temporary side effects such as fatigue and irritation of your skin.

Surgery

Surgery may be used to remove tumors in affected organs when other methods don’t relieve symptoms. One example of this is surgery to relieve pressure around your spinal cord.

Symptom management

The level of pain associated with advanced breast cancer varies from person to person. Much depends on where the cancer has spread, the size of the tumors, and your tolerance to pain.

Your oncologist can refer you to a palliative care specialist to help manage pain and other symptoms.

Other symptom management options may include drugs to treat:

  • nausea and vomiting
  • numbness and tingling (neuropathy)
  • constipation or diarrhea
  • insomnia
  • mouth sensitivities and ulcers
  • swelling
  • menopausal symptoms

You can also look into some complementary therapies such as:

  • massage
  • meditation and other relaxation techniques
  • physical therapy

Discuss alternative and complementary therapies with your oncologist.

Things to consider

If you have stage 4 breast cancer, it has spread beyond the breast and nearby lymph nodes. When breast cancer metastasizes, it usually goes to your bones, liver, and lungs. It can also spread to other organs, such as your brain.

If you were previously treated for breast cancer and it has returned, it’s called recurrent breast cancer. When formulating a treatment plan, your oncologist will review your prior treatment history.

Stage 4 breast cancer is difficult to cure. Treatment is designed to slow the spread of cancer, shrink existing tumors, and lengthen your life. Maintaining a good quality of life for as long as possible is also a main treatment goal.

Because the cancer is growing in several locations, you’ll need systemic drug therapy. Targeted therapies depend on your hormone receptor and HER2 status. Chemotherapy, hormone therapy, and targeted drugs can be used alone or in combination.

You can continue these treatments as long as the cancer is not progressing and side effects are tolerable. If it’s no longer effective, or side effects become too much, you can try other therapies. Clinical trials may be an option. Talk to your doctor to see if they recommend any clinical trials for your condition.

Discuss the pros and cons of each treatment with your doctor. Be frank about how they fit into your lifestyle and treatment goals.

Your overall quality of life is paramount, and something only you can assess.

Even if you decide to stop treatment for cancer, you can still be treated for pain and other symptoms.

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