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

Hormonal therapies

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

Current front-line therapy is typically an aromatase inhibitor (anastrozole, letrozole, or exemestane) in combination with a CDK 4/6 inhibitor.

If this combination is given to a premenopausal woman, an ovarian suppression (zoladex, lupron) treatment must also be given. The aromatase inhibitors only work when the ovaries are no longer producing estrogen.

Other anti-estrogens include fulvestrant and tamoxifen, which are also generally given with a targeted partner.

A particular line of anti-estrogen therapy is given as long as it’s working and the patient is tolerating it. When one line stops working, a second-line hormonal therapy is typically tried.

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

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

Tamoxifen can also increase your risk for blood clots.

The aromatase inhibitors increase the risk of bone loss.

The CDK 4/6 inhibitors palbociclib and ribociclib can cause low white blood cells. The CDK 4/6 inhibitor abemaciclib is more likely to cause nausea and diarrhea.

Targeted therapies

Targeted therapies for HER2-positive breast cancer include:

• trastuzumab (Herceptin)
• pertuzumab (Perjeta)
• ado-trastuzumab emtansine (Kadcyla)
• trastuzumab deruxtecan (Enhertu)
• tucatinib (Tukysa)
• neratinib (Nerlynx)
• lapatinib (Tykerb)

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

Some 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.

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 mainstay of treatment.

Chemotherapy may also be used for other types of breast cancer when more targeted therapies are no long working.

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 affected in the process, including:

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

Some chemotherapy drugs can damage your 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 or gain

Some side effects can be minimized with other medications.

For example, your doctor can recommend and prescribe anti-nausea medications. Immune boosters are also available to help your bone marrow make more healthy white blood cells to help prevent infection.

The chemotherapy drugs are administered intravenously at certain intervals, which could be weekly, every 2 weeks, or 3 weeks. Each session may last several hours. Side effects are usually worst a few days after treatment.

There are many different chemotherapy drugs that can be used to treat metastatic breast cancer. If the cancer stops responding, your oncologist can try a different drug.

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, in general, 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

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 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.

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
• 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
• acupuncture

Discuss alternative and complementary therapies with your oncologist.

If you have stage 4 breast cancer, it’s 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’s 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 with 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.