February 2004: Chemotherapy Updates

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Chemo advances for triple-negatives?

Question from Teeny: Are there any advances in chemo treatments for women who are ER/PR (estrogen/progesterone) negative and HER-2 negative? There seems to be so much hope for women with positive receptors, but we get very little info regarding cutting-edge treatments for those with negative receptors.

Answers —Jennifer Griggs, M.D., M.P.H.: It's a very common concern for women who have estrogen-receptor-negative tumors. Some of my patients struggle with this from the day of diagnosis, as soon as they understand the implications of having or not having the hormone receptors.

It's important to remember that chemotherapy - both the older and the newer drugs - are very effective in estrogen-receptor-negative cells. In fact, the benefit of chemotherapy has often been shown to be greater in tumors that don't have hormone receptors. Nonetheless, we share your frustration with the rate of progress in breast cancer care.

Marisa Weiss, M.D., president and founder: The amount of information on breast cancer has doubled in the last 10 years. It's expected to double again in the next 5 years. This means the rate of discovery of new treatment options is picking up its pace. This is hopeful.

How to prepare for chemotherapy?

Question from LenaV: I start my first chemo next week. Is there anything I should be doing mentally/physically to prepare, e.g. diet, etc.?

Answers —Jennifer Griggs, M.D., M.P.H.: Breastcancer.org has a number of helpful suggestions to help you in preparing for chemotherapy. What my patients find most helpful is learning as much about the experience as they can. Information from other patients can be helpful, but remember that each woman's story will be different from yours.

Your treatment nurses will give you information that will help you prepare. One thing that a lot of women are not aware of is that chemotherapy in breast cancer patients, for multiple reasons, can be associated with weight gain. This is one thing patients are often not told. In an attempt to help you, your friends may be bringing over lots of lovely nourishing meals, but this may not be the most helpful thing to you. Your goal is to survive this cancer. Maintaining a healthy diet and a stable weight is the best way to handle your nutritional needs.

The other thing that you may find helpful is to tell your friends and family explicitly, in great detail, what you need from them. You will find that it's more helpful to hear about people who were treated a while ago for cancer and are doing well. Surrounding yourself with well-informed people will be very helpful to you, but don't forget there's a possibility of information overload. The breastcancer.org website has a great deal of balance.

Marisa Weiss, M.D., president and founder: One thing that's very helpful to do before and during, as well as after chemotherapy, is to keep up your fluid balance. Make sure you keep drinking before and after your treatment. Keep a lot of drinks around that you enjoy, but not ones that are full of sugar. There are some nice flavored club sodas. You might enjoy chicken broth as a hot drink.

Women who forget to drink and get nervous and maybe neglect that part of their daily intake may be more likely to experience nausea. And drinking non-caloric drinks throughout treatment instead of eating can help control your weight gain a little bit.

Jennifer Griggs, M.D., M.P.H.: Trying to stay active and getting outside every day will help prevent some of the fatigue some women experience on chemotherapy.

Marisa Weiss, M.D., president and founder: As well as the tendency to feel down. Check out books on tape. Try meditation for the first time. Make sure to pamper yourself. Get that massage, sleep in late here and there, buy yourself a treat, and remind those people around you that you love presents.

No nausea after first chemo?

Question from sarahG: Does the absence of nausea and vomiting after chemo session #1 (TAC) mean that subsequent chemo sessions will have the same probability of limited nausea side effects?

Answers —Jennifer Griggs, M.D., M.P.H.: I'm pleased to hear what sounds like a fairly reasonable level of side effects with your first treatment. In general, nausea is worst with the first cycle of chemotherapy. So if you did well with cycle #1, you can probably expect to feel the same good control/ prevention of nausea with your next cycle.

Marisa Weiss, M.D., president and founder: Dr. Griggs, do you ever find that patients get worried if they experience few or no side effects because they are concerned that the treatment might not be working? Many people believe that chemotherapy has to be painful and punishing in order for it to be effective.

Jennifer Griggs, M.D., M.P.H.: I see that all the time. People want to know that the treatment they're getting is effective. I'm happy to say, quite confidently, that the absence of side effects does not indicate the absence of benefit.

How long do Taxol pains last?

Question from Renee: On average, how long should the aches and pains associated with Taxol last after each treatment? Are some of these side effects permanent?

Answers —Jennifer Griggs, M.D., M.P.H.: The muscle and joint pains that people have with Taxol (chemical name: paclitaxel) are generally nearly gone within 4 to 5 days. If you are receiving this drug once a week, this is not likely to be acceptable to you. Most physicians will help you aggressively manage this pain. Sometimes, the dose may need to be slightly adjusted to make the medication tolerable.

Although the muscle and joint pains are not permanent, the nerve tingling or numbness in the fingers and toes may be permanent. Early onset of nerve-type symptoms may indicate more long-lasting effects.

Do not hesitate to tell your doctors and nurses if you are experiencing either muscle aches or nerve problems, particularly if you are having problems picking things up or buttoning a blouse, for example.

Marisa Weiss, M.D., president and founder: The good news is that most of the numbness and tingling will eventually go away for most women. But these sensations can certainly last for an extended period of time after all your treatment is finished. If you are experiencing this type of discomfort, Dr. Griggs, what are some of the remedies and medications that you recommend for your patients to try?

Jennifer Griggs, M.D., M.P.H.: There are some people who report improvement with B-complex vitamins. I have not been impressed with resolution of symptoms with vitamin supplements, but it is certainly worth a try.

Other medications can help if you are having symptoms of pain or numbness from Taxol. There are many drugs that have been around for a decade, but these require close monitoring of blood levels. For example, Tegretol (chemical name: carbamazepine). A newer drug called gabapentin is very well tolerated by most patients. The doses can be tweaked to achieve the most benefit with the fewest side effects. It sounds as though you are experiencing short-term muscle pains, however, and your doctor can help you manage these after each cycle.

Advantage to dose-dense Taxol?

Question from Sprph: Is there any advantage to 12 weeks of Taxol vs. 4 weeks of dose-dense Taxol?

Answers —Jennifer Griggs, M.D., M.P.H.: There are studies investigating the best way of giving Taxol and the related drug Taxotere. For now, we know that these drugs are very important in women at high risk of recurrent disease.

On the other hand, for many patients, these drugs are not necessary. We are always trying to improve treatment of breast cancer, and it seems as though the progress is occurring at a faster and faster pace. Again, clinical trials are underway to answer your question.

Marisa Weiss, M.D., president and founder: Stay tuned!

Does A/C cause cognitive impairment?

Question from Rbrent: Does 4 doses of AC (Adriamycin/Cytoxan) chemotherapy cause any long-term cognitive impairment?

Answers —Jennifer Griggs, M.D., M.P.H.: This is a good question. Many women describe problems with short-term memory and with concentration when receiving really any chemotherapy. Some of the changes in cognitive function (thinking and concentration) can be due to a variety of problems, such as sleep disturbance, fatigue, information overload, a busy lifestyle, and depression and anxiety.

I would say that long-term memory problems (persisting or lasting more than one to two years) are uncommon. If you are affected, however, this can be a very troubling, annoying, and frustrating effect of chemotherapy. The hormonal changes that chemotherapy can cause, such as "chemopause," may be responsible in large part for the memory and concentration problems.

Marisa Weiss, M.D., president and founder: For many women, on the heels of chemotherapy as well as the abrupt onset of menopause as Dr. Griggs has described, they may go on to take anti-estrogen therapy. This hormonal therapy may also have an impact on thinking and remembering. And, of course, as we all know well, growing older does gradually reduce your ability to think as clearly as you did when you were younger. This also factors in.

Jennifer Griggs, M.D., M.P.H.: It's important when you're undergoing chemotherapy to cut out any stress that you can and to recruit all the support that you can. This may help you get through such a stressful time more smoothly.

Marisa Weiss, M.D., president and founder: And watch out for all those damned expectations you put on yourself! As Dr. Griggs is saying, you have to give yourself the space and kindness that you need to get through and beyond this.

How to minimize cognitive effects?

Question from Rbrent: What strategies can you use to minimize any cognitive effects of chemo while you are going through it?

Answers —Jennifer Griggs, M.D., M.P.H.: In addition to the hints and tips on breastcancer.org, maintaining good sleep habits, and getting fresh air—as much as possible.

Marisa Weiss, M.D., president and founder: Maintaining as many of the rhythms in your life can be useful. Keep a fairly regular schedule so your body can adjust and know what to expect from day to day. Figure out a system that helps you remember the important things. Writing a list can be very helpful. Putting your keys in one place. Hey, even ask kids to wear name tags if necessary!

What's the "gold standard" chemo?

Question from Annie: What is the "gold standard treatment" to have for chemo? I live in England and there are two trials for me to think about before I start next week.

Answers —Jennifer Griggs, M.D., M.P.H.: I always tell my patients that the gold standard is both personalized and ever-changing. So what we considered the gold standard two years ago may change today because of clinical trial. If a clinical trial is offered to you, you can trust that your physician does not actually know which is the best treatment—thus the need for the clinical trial.

In terms of deciding between the two trials, some of this may depend upon your approach to your treatment. Some women will choose a trial comparing two "aggressive" treatment strategies. Other women want to have as little treatment as possible. Make sure that you are comfortable before you participate in a clinical study. Sometimes obtaining a second opinion can help you make a decision as well.

Marisa Weiss, M.D., president and founder: It's reassuring to know that there are many different options that represent today's "gold standard." But it's also true that having a lot of options can feel overwhelming and confusing.

Jennifer Griggs, M.D., M.P.H.: You should make sure that you spend time with your physicians understanding the purpose of the trials, the goals of therapy, and what about your particular situation makes the trial right for you.

Cytoxan necessary in dose-dense regimen?

Question from Sprph: How necessary is Cytoxan in the sequential dose-dense regimen?

Answer —Jennifer Griggs, M.D., M.P.H.: Cytoxan (chemical name: cyclophosphamide) is one of the oldest drugs known to be effective against breast cancer. It would probably be going too far, however, to say that this will always be considered necessary.

We have trials in women with negative lymph nodes that are attempting to answer this question. Until we have studies saying that it is OK to skip this drug, I would recommend it as standard of care. If there is a reason that you cannot have this drug, your physician will discuss other options with you. Many women read about Cytoxan and are concerned about the risk of long-term effects. At the doses used in treating breast cancer, however, such long-term effects are very rare.

Pneumonia vaccine before chemo?

Question from KySandy: I started my chemo two weeks ago. It seems of all the surgeons and doctors I've been to, no one suggested a pneumonia vaccination. I was diagnosed with bacterial pneumonia just 10 days after my first treatment.

Answer —Jennifer Griggs, M.D., M.P.H.: It is very much a possibility that even if you'd received the shot, you may still have had this complication. The pneumonia vaccine is effective in many patients against one type of bacterial infection. Receiving an immunization and then starting chemotherapy may lower the effectiveness of the immunization. It is not my standard practice, therefore, to recommend the pneumonia vaccine before starting chemotherapy.

Irritated sinuses with chemo?

Question from Patti: I have advanced breast cancer in bones for three years, liver for one year. After AC chemo I had to switch to Taxol, now Taxotere. With Taxol and Taxotere, my sinuses have become dry, irritated, and swollen. My doctor says it's not the chemo. What to do?

Answers —Jennifer Griggs, M.D., M.P.H.: I have seen problems with Taxotere with sinuses, but patients usually describe small amounts of blood upon blowing their nose. Your doctor may be agreeable with you trying a saline nose spray, particularly one made for children.

A brief break from chemotherapy, if your doctor is agreeable, may help you determine the relationship between the chemotherapy and what sounds like a very troubling symptom.

Marisa Weiss, M.D., president and founder: During the wintertime, the air in most people's homes becomes very dry. You may notice a dryness of your mouth, your nose, your skin, etc. If you have irritation of your nose and a cold, you might find that you have a little bleeding when dry tissues are irritated further.

Sometimes, these symptoms can be improved by using a humidifier or by simply putting trays of water on top of your radiator. You can also use Vaseline or a petroleum jelly on your lips and nostrils when you get a cold. Sometimes, certain chemotherapies can also irritate the mucous membrane inside your nose, mouth, vagina, etc. Ask your doctor about this.

Doing alright with chemo until end?

Question from Flyby: I did so well throughout chemotherapy, 4 AC and 4 Taxotere, every 3 weeks. Why did I do so badly after the last Taxotere? Is it the lack of steroids?

Answer —Jennifer Griggs, M.D., M.P.H.: Unless you were on steroids every day, which would be uncommon, you are most likely experiencing the cumulative effects of eight treatments. It is common for healthy women to feel as if they are "sailing" through chemotherapy until the very end.

There is also sometimes a "let down" after chemotherapy is over. Just when you think you should be celebrating, you find yourself feeling very vulnerable. This can lead to depression, anxiety, and a sense of isolation. In addition, you may be developing anemia after two types of chemotherapy.

Now that you are off the chemotherapy, this should start to get better over the next few months. It's important to remember that it can take up to 12 months to feel your "normal" self after all that chemotherapy. breastcancer.org has a lot of information on how to make the transition from going through treatment to living after breast cancer.

Special chemo for liver metastases?

Question from Janie: What special chemotherapy is there for women with liver metastases?

Answer —Jennifer Griggs, M.D., M.P.H.: Treatment decisions for any type of metastases (tumor that has spread away from the breast and the nodes) are based on several factors. Those are: previous treatment, your liver function (which can be determined with routine blood tests), whether the tumor is hormone-receptor-positive, and your overall health. These all play a role in a choice of chemotherapy. Hormone therapy is not necessarily eliminated as an option if your tumor has the hormone receptors.

In general, chemotherapy for liver involvement from breast cancer is given like the chapters of a book. In other words, we use one drug as long as it works and as long as you're tolerating it. If or when that drug stops working, we try another drug. The goal overall, however, is to make you feel as good as possible. New drugs are being developed all the time. A drug that was not available to you six months ago may be available now.

Genetic test for giving chemo?

Question from MaryR: Regarding the new genetic test that will help predict whether cancer will recur and whether chemotherapy should be given: Is there any reason for someone who has been through chemo [1.2 tumor, node negative, ER+], 4 rounds of AC, and is on tamoxifen to be tested under the theory that if the test indicates higher probability of recurrence, additional chemo [Taxol, etc.] should be administered?

Answers —Jennifer Griggs, M.D., M.P.H.: This is one of the most exciting and hottest areas in breast cancer care. It will be wonderful to know who really does and does not need chemotherapy.

It is probably premature to say that these genetic tests will help us pick the best chemotherapy. Most promising with this technology is the thought that we can avoid chemotherapy altogether in women who don't need it. I would not recommend at this point that your tumor be tested for the genetic profile, particularly as you have completed very good chemotherapy.

Marisa Weiss, M.D., president and founder: This new test was just FDA-approved. It looks at many different genes together to look at the pattern of which ones are normal and abnormal. It tries to get a "big picture" of which cancers are favorable and which ones are more likely to act in an aggressive manner. All of us are watching this new test closely. As soon as more solid information is available, we will let you know.

Taxol increases toxicity of radiation?

Question from PlainJane: Does Taxol increase the toxicity of radiation?

Answers —Jennifer Griggs, M.D., M.P.H.: The taxanes (both Taxol and Taxotere) are radiosensitizers. This means that they give sort of a one-two punch to cancer cells. We may eventually use the combination to increase response rates to radiation therapy.

Giving a taxane with radiation at the present time is, however, investigational. Another thing you can see is that giving a taxane after radiation therapy can lead to something called "radiation recall." Areas that received radiation before can become red, as if you just completed radiation therapy, even if it's many months or even years later.

Marisa Weiss, M.D., president and founder: You can also get radiation recall from Adriamycin (chemical name: doxorubicin) chemotherapy. In general, it's a good idea to avoid giving radiation at the same time as some of these powerful chemotherapy drugs, unless there is definite proof that giving them at the same time is likely to add substantial benefit. At this point, that benefit is unproven and the side effects are higher.

Are blackened nails normal?

Question from RK: My mother is going through six doses of chemo. After the third dose, besides losing all her hair just after the first dose, her nails have blackened. Is this a normal side effect? Will her nails return to their normal color?

Answers —Jennifer Griggs, M.D., M.P.H.: Skin and nail changes can be seen with several different types of chemotherapy. Women with darker complexions notice this more. You can even see dark pigmentation in the mouth.

All of these changes are reversible and will go away. Toenails can take a long time to grow back to normal. Fingernails tend to grow more quickly. If your mother is receiving Taxotere and develops pain or drainage in the fingernails, she should see her doctor and possibly be treated for an infection if one is shown to be present. If she is just having darkening of the nails with no pain or drainage, there is no need for concern. Some women can feel very self-conscious about this effect, however, and telling her that these are normal side effects may help her feel better.

Marisa Weiss, M.D., president and founder: Is it OK to wear dark nail polish on your toenails to hide some of these changes?

Jennifer Griggs, M.D., M.P.H.: You can wear nail polish on both toenails and fingernails unless you have pain or drainage. In that case, nail polish could hide an infection.

Marisa Weiss, M.D., president and founder: What about those glue-on nails?

Jennifer Griggs, M.D., M.P.H.: Many women with acrylic or other false nails choose to remove them. Ask your doctor whether it is OK for you to keep them on. Some women notice during chemotherapy that their nails grow quickly and are strong, making the artificial nails more of a pain in the neck than a help.

More chemo after 6x CMF?

Question from Tonio: Hello from Spain. My wife, 37 years old, was diagnosed with invasive ductal carcinoma (T1N0M0), 2 cm., ER+, PR+, c-erbB-2- (HER-2/neu negative). She has been treated with 6 x CMF, finishing last week, but we believe that it is not the optimum treatment. Would it be possible to add any anthracycline or taxane regimen now?

Answer —Jennifer Griggs, M.D., M.P.H.: Actually, the treatment you've outlined is excellent. Although very large studies suggest a possible benefit to regimens that contain an anthracycline, there are no features of your wife's tumor that make me think this class of drug would be necessary. I am assuming that she will also go on a hormonal-acting agent, such as tamoxifen.

Tumors that have the c-erbB-2- (in other words, are negative for HER-2/neu) can get a good response to CMF chemotherapy as well as to Adriamycin chemotherapy, but tumors that are HER-2 positive may respond better to an Adriamycin-based or a taxane-based chemotherapy.

Chances of Xeloda working?

Question from Susie: What are the chances that Xeloda will work? My mom has Stage IV metastatic breast cancer, which has spread to her bones and lungs. She was in remission on Femara for 18 months and tamoxifen did not work. She started on 500 mg 2 x day Xeloda two weeks ago.

Answers —Jennifer Griggs, M.D., M.P.H.: I wish your mother weren't going through this. The drug that she is starting on, which is an oral drug as you know, is one of our most effective drugs in breast cancer.

It's hard to wait to see if the drug is working, but if she is tolerating it, she should stay on the medication for approximately three months before her doctor will redo her scans. Although, obviously, not all women have a response to this drug, we have been impressed with the number of women who do benefit.

Marisa Weiss, M.D., president and founder: If the chemotherapy worked, then it worked. It really can be that simple. Dr. Griggs and I have many patients who are able to take this chemotherapy by pill and keep things under control for an extended period of time. You don't know until you try it.

It sounds like, for your Mom, it's worth trying. Be reassured that with any treatment that you are placed on, your doctors will be there to re-evaluate all along the way to make sure that the benefits are outweighing the side effects. If the benefit isn't there, something else can be tried.

Pain in feet after chemo?

Question from Lpfiner: My husband had chemo last year and he still has pain in his feet caused by it. Is there anything that can help him? Pain medicine doesn't seem to be enough.

Answers —Jennifer Griggs, M.D., M.P.H.: Depending upon the type of treatment he received, the long-term effects are different in each person. The doses of chemotherapy that we give are chosen because they were shown to be the most effective and the safest doses for breast cancer treatment. Some of the best drugs, the taxanes (such as paclitaxel and docetaxel) can affect the small nerve fibers in the hands and feet. The pain that you describe in your husband's feet may respond best to drugs that work on nerve pain. Examples include carbamazepime and gabapentin. The pain medicines we usually think of probably won't work on this type of pain.

In my opinion, the most serious and common long-term side effects are those in women who go through menopause related to chemotherapy. We are learning more and more about the effects of chemotherapy on bone density, for example. But we have very little research on this in men. It would be important that your husband speak with his doctor, not necessarily his cancer doctor, about checking out his bone density. This is done with a non-invasive test that his primary doctor can order.

Marisa Weiss, M.D., president and founder: As time goes by, after treatment's finished, all the regular and ordinary stresses of life also continue. Life these days is a real challenge -- even without breast cancer. As we move through our lives, these stresses can add up. Plus, there are just the effects of aging, growing older, over time. We need to be aware of this.

Options if can't metabolize chemo?

Question from Kathy: I received my first dose of AC six weeks ago and have not been able to continue with the next three doses due to an extreme reaction to the chemo. My oncologist said my body did not metabolize the drugs and he is not sure I can tolerate chemo in the future. I was being treated for Stage II breast cancer after a mastectomy and am Her2neu+. I am concerned about what options are open to me without chemo.

Answer —Jennifer Griggs, M.D., M.P.H.: It sounds as if you certainly had a difficult time with your first treatment. I would speak very candidly with your physician about your concerns. I have had two or three patients who were not able to stay on AC chemotherapy. I treated all of these patients with single-agent taxane (Taxol or Taxotere). This would be a very reasonable option in your case given that you are motivated to do all that you can against the breast cancer.

You may find it helpful to seek a second opinion, particularly as your situation is uncommon. Although it can be stressful to change doctors in the middle of your treatment, you need to feel confident that you are receiving the best care. This is not to say that you are not with the best doctor right now. You can ask your primary physician for help in navigating such a change if you think this might be helpful to you.

Alright to work while getting chemo?

Question from Janice: I am an RN working in a walk-in treatment center. I will be starting chemo next week. If my counts remain OK, should it be OK for me to work?

Answers —Jennifer Griggs, M.D., M.P.H.: Working is important to many women for several reasons, such as finances, maintaining a normal routine, and maintaining your sense of who you are as a person. Unless your doctor tells you otherwise, working should be fine and perhaps very helpful to you.

If you are working with people who have highly contagious diseases such as tuberculosis, however, a change in your job description may be appropriate. Your doctor, who knows your situation the best, can help advise you in this decision.

Working during chemotherapy does not make you a better person. There is no need to be "superwoman." Nonetheless, if working is important to you, explore this with your doctor.

I can usually tell which patients will keep working based on how they ask the question. For example, if a woman says, "Is it possible for me to hook onto the Internet while I'm getting my chemotherapy so I can stay in touch with work," working will be very important to her. Another woman might ask, "I don't have to work during this, do I?" Work will be much more troublesome to her as she already has mixed feelings about her job. You may be somewhere in the middle.

Marisa Weiss, M.D., president and founder: If you are worried about taking time off from work, ask your doctor to help you. A very simple note from your doctor to your employer can ease the way and take the pressure off you. Even taking a few days to a few weeks off can make an enormous difference to you and your recovery.

Criteria for reducing chemo doses?

Question from Applepie: What criteria do you use to decide whether the patient cannot tolerate AC chemo treatment side effects any more?

Answer —Jennifer Griggs, M.D., M.P.H.: It sounds as if you or somebody you know is having a tough time with treatment. Some people are sensitive to the drugs and cannot receive the full doses. Although we do not generally recommend reducing doses, sometimes a "slight" reduction in the dose can work wonders.

In general, side effects that resolve by the next treatment cycle do not mandate a change in either the drugs or the dose. If you don't bounce back or almost bounce back, you may need to consider an alternative approach with your doctor.

How often are blood counts done?

Question from Abdul: How often should blood cell counts be done during four cycles of chemo?

Answer —Jennifer Griggs, M.D., M.P.H.: In general, we check blood counts the day of chemotherapy or the day before chemotherapy. Unless you are feeling ill, having a fever, or having other severe side effects—such as a drop in blood pressure—there is probably no need to check your blood counts more often than that. If you are on a clinical trial, the study may ask you to have your blood work done more often, but this is not usually the case anymore.

Cut hair before chemo?

Question from Donna: I'm starting chemo next week. I know I will lose my hair. My hair is long; should I cut it now and can I use my own hair for a wig? If so, who can help?

Answer —Jennifer Griggs, M.D., M.P.H.: If you cut your hair before it falls out, many professional wig makers will be able to style you a natural-looking wig with your own hair. You can also have a ponytail or bangs made from your own hair to wear under a hat or scarf.

You might be amazed at the quality of the wigs you can get without using your own hair. This can save you hundreds and hundreds of dollars. I would recommend that you speak with a nurse at your treatment center about people s/he may have worked with in the past. Women with very long hair have also donated their hair before it falls out to an organization that makes wigs for children. The organization is called Locks of Love.

How much chemo can a body take?

Question from Chat: How much chemo can a body take? I did 6 treatments of Taxol/carboplatin/CMF adjuvant (every 21 days) and was on Herceptin every week. I also do Aredia monthly. I went into remission for 90 days and the cancer acted up again, so now I was put on Adriamycin only. Next my doctor is talking about Taxotere and Herceptin again. I feel my body is getting beat up from all this chemo. I just want to know how much can a body take?

Answer —Jennifer Griggs, M.D., M.P.H.: You have been down a long road. Your question is a very common one we face. You are in a position where you are now balancing side effects, both long- and short-term, and your desire to continue to be treated.

In general, most drugs can be used until you develop a side effect that you actually know about; for example, numbness from Taxol. Adriamycin can cause heart problems as you get more and more of the drug. So, in this case, as you get more and more Adriamycin, you may need to stop receiving the drug. You may want to talk to your doctor about a break from chemotherapy if you are experiencing bad side effects.

Difference between Adriamycin and Cytoxan?

Question from Sprph: What is the difference in mechanism of action of Adriamycin vs. Cytoxan? Both act on cell-wall replication, so why both?

Answer —Jennifer Griggs, M.D., M.P.H.: Both drugs actually work on DNA, rather than cell walls, but the drugs actually work in different ways. For example, Adriamycin has several ways in which it works. There is no reason to think that receiving both drugs is redundant.

Switching chemo regimens?

Question from KySandy: I just had one session of FAC 100. Now I see studies indicating a much better response to TAC. Once you begin a therapy, is it ever switched?

Answer —Jennifer Griggs, M.D., M.P.H.: Your question is a good one and you have seen first-hand how quickly breast cancer care changes. FAC certainly is one of the "tried-and-true" recipes. There is one study that has suggested that a Taxotere-containing regimen may provide a benefit in some women.

It would be worth talking to your doctor about whether receiving a taxane after your FAC would give you additional benefit. It is so hard to know how to interpret the results of a study for your individual case. This may be another situation where a second opinion might help.

Rebuilding veins after chemo?

Question from Dragonfli: Is there any way to help rebuild your veins after receiving harsh chemotherapy that has hardened and damaged the veins?

Answers —Jennifer Griggs, M.D., M.P.H.: These changes in the veins usually go away within a few months after completing chemotherapy. If you are having repeated problems with your veins, you may want to talk to your doctor about having a port. Breastcancer.org has a lot of information about ports.

If you are done with your chemotherapy, however, just be patient. If you are having pain at the site of a previous IV, ask your doctor if you can take an anti-inflammatory drug and if ice might help if applied to that area on your arm.

Marisa Weiss, M.D., president and founder: Heat may also be helpful.

Recovering energy after chemo?

Question from Marsha: Is there a harmless drug that can bring back my energy level? I had AC with Taxol, then radiation, over two years ago. I still find myself almost falling asleep at the wheel during my 45-minute trip to and from work. I have a great diet, and exercise now and then. Thanks in advance.

Answers —Jennifer Griggs, M.D., M.P.H.: It sounds as if you are one of the people who continues to experience fatigue a long time after your treatment is over. You are also aware of your body, maybe more than you were before.

It would be important to make sure you are not experiencing other possible causes of fatigue, such as thyroid problems, sleep problems, or anemia. These may have nothing to do with your breast cancer treatment. If no physical cause can be found for your fatigue, exercising more often may help you regain your energy.

It is also possible that you are experiencing a neurological problem that we call depression. One of the most common effects of depression is a lack of energy. Depression occurs in 1 in 6 people, regardless of breast cancer history.

Marisa Weiss, M.D., president and founder: Sometimes, also, medications that treat depression can add to fatigue. Work closely with your doctor to find the best medications for you.

If you find yourself falling asleep at the wheel, then it's unsafe for you to be driving in that condition. Can you take the train, or a bus? Can you carpool with a friend until you figure things out? Will a cup of coffee do the trick? Make sure you wear your safety belt. A stop along the way to work, with a good stretch, may make a difference, too.

Jennifer Griggs, M.D., M.P.H.: I can't emphasize enough how helpful exercise can be. Despite the fact that you don't feel like it, exercising in the morning is more likely to help your energy level than exercising at night, when it can interfere with your sleep.

Marisa Weiss, M.D., president and founder: You can read more about this in our section on fatigue.

What is "comfort chemo?"

Question from Carrie: I have breast cancer, and I am in Stage IV. I have had 5 rounds of chemo and am finishing up on radiation of 7 weeks. They say I will be on comfort chemo after this—just what is that?

Answers —Jennifer Griggs, M.D., M.P.H.: Your doctors are using the term "comfort chemo" to emphasize that the purpose of treatment is to make you feel better. In other words, if you feel worse on treatment than you did off of treatment, you need to work with your doctor to achieve the best quality of life possible.

Marisa Weiss, M.D., president and founder: You might want to visit the breastcancer.org discussion boards and chat rooms where you can connect with other women who can support you through your on-going therapy.

Jennifer Griggs, M.D., M.P.H.: Having Stage IV breast cancer can feel very lonely, and it doesn't need to.