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CHEMOTHERAPY

“Let’s walk side by side through this journey.”

–Rahul Singh, MD-Medical Oncologist

Your Biopsy Results
The Difference Between Staging and Grading
Medication-Endocrine Therapy
Medication-Chemotherapy
Immunotherapy
Our Long Term Connection
Chemo-From a Patient’s Perspective
Oncologists: Their Role in Your Journey

Oncology is the study of cancer. An oncologist is a doctor who treats cancer and provides medical care for a person diagnosed with cancer. An oncologist may also be called a cancer specialist.

The field of oncology has 3 major areas based on treatments: medical oncology, radiation oncology, and surgical oncology.

Medical oncologists treat cancer using medication, including chemotherapy, immunotherapy, and targeted therapy.

Radiation oncologists treat cancer using radiation therapy, which is the use of high-energy x-rays or other particles to destroy cancer cells.

Surgical oncologists treat cancer using surgery, including removing the tumor and nearby tissue during a operation. This type of surgeon can also perform certain types of biopsies to help diagnose cancer.

There are also medical terms for oncologists who specialize in caring for specific groups of patients or groups of cancers.
(cancer.net)

As oncologist we help manage you through the diagnosis and make sure the right parties are involved in your care.
Our main tool is the medication aspect of your treatment
An analogy I like to use, albeit sports related, we are the “quarterback” of your team.

An oncologist manages a patient’s care throughout the course of the disease. This starts with the diagnosis. Their role includes:

Recommending tests to determine whether a person has cancer

Explaining a cancer diagnosis, including the type and stage of the cancer

Talking about all treatment options and your treatment choice

Delivering quality and compassionate care

Helping you manage symptoms and side effects of cancer and its treatment

(cancer.net)

We determine if treatment in the method of medications are needed.

Your Biopsy Results

Unless we are able to determine the exact cause of the suspicious lesion noted in your breast we cannot determine what the next step would be in management.

A phrase we oncologist like to use: “Tissue is the Issue”

It gives us very important information regarding the tumor type, size, grade, and molecular markers.

A lot of factors play into determining this such as size, and molecular markers.

A combination of any of the following positive or negative:
1. Hormone receptor
2. Her-2/neu receptor

Breast cancer cells express the hormones estrogen (ER-positive) and/or progesterone (PR-positive) which drives the cancer cells to grow and spread. Just needs to be 1% positive to qualify.

This means you have no molecular marker that can be targeted (ER/PR or Her-2/neu)

Involved lymph nodes means the cancer has jumped outside the the primary breast site, which can affect the type of treatment required. Different scans can help us determine if there is cancer anywhere else in the body.

Biopsy results can take up to a week or longer depending on certain molecular tests. The biopsy is reviewed by a physician called a pathologist and interpreted as well by your oncologist/surgeon.

It is one the major parts of the story as it begins the path of determining what is involving your breast and how to move forward for management

In certain situations, such as high risk genetics we need to also treat the other breast, but in most cases we are focused only on the breast involved.

The Difference Between Staging and Grading

Staging: Staging is the process of finding out how much cancer is in a person’s body and where it’s located. The cancer stage is also a way for doctors to describe the extent of the cancer when they talk with each other about a person’s cancer. A cancer’s stage can also be used to help predict the course it will likely take, as well as how likely it is that treatment will be successful.

Grade: Grade is a measure of how abnormal the cancer cells look under the microscope. This is also called differentiation. Grade can be important because cancers with more abnormal-looking cells tend to grow and spread faster. www.americancancersociety.com

For most cancers, the stage is a Roman numeral from I (1) to IV (4).

Stage 0, which is often called carcinoma in situ or CIS, (CIS is not cancer, but it may become cancer) means the cancer is still only in the layer of cells where it first started, and it has not spread any farther.

Stage I II & III- Cancer is present. The higher the number, the larger the cancer tumor and the more it has spread into nearby tissues.

Stage IV – The cancer has spread to distant parts of the body. Most common areas include the brain, bones and lungs.

Sometimes stages are subdivided as well, using capital letters (for example, stage III might be subdivided into stages IIIA and IIIB).

The American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC) maintain the TNM classification system as a way for doctors to stage many different types of cancer based on certain common standards.

In the TNM system, the overall stage is determined after the cancer is assigned a letter or number to describe the tumor (T), node (N), and metastasis (M) categories.
T describes the original (primary) tumor.
N tells whether the cancer has spread to the nearby lymph nodes.
M tells whether the cancer has spread (metastasized) to distant parts of the body

Grade is determined on the biopsy and stage is dependent on the size, lymph nodes involved, and if disease is found outside of the breast on scans .Staging of breast cancer is how we determine the extent of involvement by the disease

For Hormone positive, Her-2/neu negative breast cancers that are local, we use a 21-gene recurrence score to determine if someone needs chemotherapy or not after primary treatment’
Types: Mammaprint, Oncotype Dx,

Medication-Endocrine Therapy

Used for Hormone receptor-positive breast cancer.

If cancer is driven by hormones, then simply blocking it will cause the cancer to die.

In certain situations is just effective alone in preventing recurrence of cancer.

Two Major Types:
1. Tamoxifen
2. Aromatase Inhibitors

It is common to switch from one medication to another if you experience side effects.

Depending on the stage of your disease it can range from 5-10 years.

Breast cancer index helps us determine the risk of your cancer returning in 5-10 years and as such will help us figure out how long one will need to stay on the medication.

Aromatase Inhibitors:
1. Muscle and Joint Aches; worsening of arthritis symptoms
2. Bone loss (osteoporosis/osteopenia)
3. Sexual Dysfunction
4. Hair Thinning
5. Forgetfulness
i. Tamoxifen
1. Hot Flashes
2. Vaginal Dryness or discharge
3. Increased risk of uterine cancer ( less than 1% chance per year)
4. Blood clots

Increased chance of recurrence of your breast cancer, tend to be seen later with hormone positive breast cancer.

Medication-Chemotherapy

Chemotherapy refers to the use of any drug to treat any disease. But to most people, the word chemotherapy (or “chemo”) means drugs used for cancer treatment. Chemo is considered a systemic treatment because the drugs travels throughout the body, and can kill cancer cells that have spread (metastasized) to parts of the body far away from the original tumor. This makes it different from treatments like surgery and radiation.
(American Cancer Society)

Chemotherapy medicines prevent cancer cells from growing and spreading by destroying the cells or stopping them from dividing. Cancer cells tend to grow and divide very quickly with no order or control. Because they’re growing so fast, sometimes cancer cells break away from the original tumor and travel to other places in the body. Chemotherapy weakens and destroys cancer cells at the original tumor site AND throughout the body.
Goals of Chemotherapy:
-To shrink a tumor before surgery or radiation therapy. Chemo used in this way is called neoadjuvant therapy.
-After surgery or radiation therapy to help kill any remaining cancer cells in the body. Chemo used in this way is called adjuvant therapy.
-With other types of drugs to help kill cancer cells, such as targeted therapy drugs that act on certain targets of cancer cells or immunotherapy drugs that help the immune system fight cancer.
-With other treatments if cancer comes back or doesn’t completely go away.
(American Cancer Society)

In many situations this is the only option of treatment as we are either unable to target a specific mutation or the cancer is too aggressive.

-Oral
-IV
. Many different types but the commonly administered chemotherapies are:
1. Paclitaxel (Taxol)
2. Adriamycin (Red Devil)
3. Carboplatin (Carbo)

Wide range which includes but is not limited to drop in blood counts, loss of hair, neuropathy, fatigue, weakness, lethargy, change in heart function, diarrhea, nausea/vomiting.

How often you get chemo and how long your treatment lasts depend on the kind of cancer you have, the goals of the treatment, the drugs being used, and how your body responds to them.

You may get treatments daily, weekly, or monthly, but they’re usually given in on-and-off cycles. This means, for example, that you may get chemo the first 2 weeks and then have a week off, making it a cycle that will start over every 3 weeks. The time off lets your body build healthy new cells and regain its strength.

Your cancer care team can tell you how many cycles are planned and how long they expect your treatment to last. www.americancancersociety.com

IV – Many types of chemo are given as an infusion or injection. With chemo infusions, chemotherapy drugs are put into your body through a thin tube called a catheter that’s placed in a vein, artery, body cavity, or body part. In some cases, a chemo drug may be injected quickly with a syringe.

Intravenous drugs are given in these ways:
-IV push: the drugs can be given quickly through the catheter right from a syringe over a few minutes.
-IV infusion: a typical infusion can last from a few minutes to a few hours. A mixed drug solution flows from a plastic bag through tubing that’s attached to the catheter. The flow is usually controlled by a machine called an IV pump.
-Continuous infusion: These infusions can last anywhere from 1 to several days and are controlled by electronic IV pumps.

Oral – If chemo is taken by mouth, you swallow the pill, capsule, or liquid just like other medicines. Like other types of chemo, sometimes chemo is given in rounds or cycles. This cuts down on the harm to healthy cells and allows the chemo to kill more cancer cells.

Oral chemo is usually taken at home. Because of this, it’s very important to make sure you know exactly how it should be taken.
Topical – Topical chemo is put right on the skin in an area where certain cancers are. Topical chemo can be a cream, gel, or ointment.

Chemo drugs you use on your skin are as strong as other forms of chemo. Many are also considered hazardous. If you are using topical chemo, be sure you know the precautions you need to take when storing, handling, and disposing of the tube or container it comes in. www.americancancersociety.com

Many side effects go away fairly quickly, but some might take months or even years to go away completely. These are called late effects.

Sometimes the side effects can last a lifetime, such as when chemo causes long-term damage to the heart, lungs, kidneys, or reproductive organs. Certain types of chemo sometimes cause delayed effects, such as a second cancer that may show up many years later. www.americansociety.com

Immunotherapy

Checked by a test called immunohistochemistry (IHC)
i. Positive result:
1. 3+ on the test or 2+ with a specific test called ISH meeting a specific threshold
2. Negative results is 0 or 1+
ii. If positive it means we can use a drug to target the Her-2 which drives the breast cancer

Immunotherapy is treatment that uses a person’s own immune system to fight cancer.

Uncommon but auto-immune disorders such as thyroid disease can be seen, along with diarrhea, cough, drop in blood pressure, among others.

Our Long Term Connection

Depending on the stage of breast cancer, it can range from every 3-4 months to every 6 months.

Depending on the stage of breast cancer we can gather a lot of information from blood work which could include monitoring the cancer, assessing tolerance to treatment, and evaluating for recurrence of disease

Once completed with definitive treatment (surgery, radiation, and/or chemotherapy/hormone/targeted therapy) we consider patients to be in remission which can be considered as cancer free.

Remission means there is no identifiably evidence of cancer
“NED” stands for No Evidence of Disease

i. Depending on timing in your treatment, there are several tests that can be used to assess for recurrence
ii. The American Society of Clinical Oncology (ASCO) supports the use of the following biomarker assays to guide decisions on treatment therapy after surgery/radiation for women with early-stage breast cancer:
1. Oncotype DX 21-gene Recurrence Score
2. EndoPredict
3. Predictor Analysis of Microarray 50 (PAM50
4. Breast Cancer Index
5. Amsterdam 70-gene profile (MammaPrint)

Symptoms of local recurrence could include noticing a firm, non-painful, fixed spot, or skin dimpling, discoloration and changes in your breast.
Should you notice any of this on a self-breast exam, recommend notifying your oncologist or surgeon to have this evaluated immediately.

Chemo-From a Patient’s Perspective.
Sammie, Emotional Contributor
Questions to consider asking before treatment
  • What chemotherapy drugs will you be receiving and how often will you get them?
  • What side effects can I expect and how do I manage them?
  • Will I lose my hair?
  • Do you know how I can preserve my hair if I lose it?
  • Can you write me a prescription for a head prosthesis (wig)?
  • Most Insurance Companies will cover a Wig Purchase. Call your doctor and ask about a prescription for a wig. It should be written for a “Hair prosthesis” or “Cranial Prosthesis.”
  • Will I have prescriptions that need to be filled?
  • If I run low, who should I call?
  • How long will I be at the chemotherapy clinic for each treatment?
  • What can I eat or drink before each chemotherapy session?
  • How can I get a hold of the healthcare provider, if I need to, during the day or evening?
  • What is the cost of chemo and insurance, and is there someone that can help me financially?
  • If the chemo does not work are there other options?
  • Do I need a port?
  • Should I make any lifestyle changes or change my diet?
  • fuzzy socks
  • warm fuzzy blanket
  • pillow and eye mask
  • water
  • books
  • tablet or laptop
  • adult coloring book or crossword puzzles
  • headphones to listen to music
  • candies to suck on or chewing gum
  • healthy snacks
  • chapstick
  • tissues
  • sunglasses (some chemo makes you sensitive to light)
  • pen and binder to keep all your information in one place
  • A support person (if possible)
  • See the Dentist: Chemo can put you at risk when it comes to getting infections. It is best to have dental work BEFORE treatment.
  • Have a PAP Smear: It is best to have your annual PAP before chemo. Sometimes chemo can cause a false-positive reading.
  • Buy a Wig: Sometimes a cancer center will have a wig center that will be able to find a wig that matches your original hair. Or, go with a friend and family member to a wig store, and have a wig fashion show to see which ones you like the most. Check with your insurance company to see whether they will pay for a wig; if they do, you will need your healthcare provider to write a prescription for a “cranial prosthesis.”
  • Discuss Fertility Options: You may want to see a fertility doctor before you start treatment as it can lead to infertility.
  • Ask About Cold-Capping: A cold cap is a special hat that’s worn during chemo that protects your hair from falling out. This may or may not be covered by insurance.
  • Have a Cancer Binder: This will help you stay organized throughout your cancer journey. https://www.oncolink.org/treatment-binder
  • Lotion is your friend: Chemo dries your skin out, so make sure you have lotion on hand.
    Water is key: A lot of chemo side effects can cause you to become dehydrated. Not only can this cause you to be nauseous and have low energy, but it can also cause other health issues. Also, the more you drink, the faster it flushes the chemo out of your system so you can begin to recover sooner.
  • Eat small meals: Although chemo might make you nauseous or cause a loss of appetite, it is important to eat when you can to avoid malnourishment.
  • Try to stay as active as possible: Exercising during chemo can help ease side effects, such as fatigue and nausea, and can help boost your immune system. So even on days you don’t want to get out of bed, going for a walk will do you wonders.
  • Keep a chemo journal: It is important to track your systems so you can discuss them later with your health care team and talk about how to alleviate them. Believe it or not, your team does not want to torture you.
  • Listen to your body: If you are tired, sleep! Your body is going through a war and needs all the rest it can get.
  • Have a sysport system: Whether it is family, friends, a facebook group or what, it is so important to have support during your journey. It often helps to talk to other survivors who know what you are going through and can offer advice and tips on how they coped.
  • Keep a schedule: A lot of patients find that if they are on a schedule it gives them a sense of normalcy, and keeps sleeping patterns consistent to combat fatigue.
  • Prioritize your mental health: Maintaining a positive attitude and talking about your feelings to a therapist or cancer coach can help you process your emotions and deal with the emotional trauma.
  • Utilize resources: There are so many assistant programs and resources available to breast cancer patients now that it would be foolish not to utilize them. Check out what your local hospitals, cancer centers or non profits are offering.
  • Accept Help: People are always asking how they can help…here is how! Make a list of all the items you will need, whether it be for chemo, your mastectomy, radiation, etc. Then send the list out to all your friends and family and have them sign up for items they want to purchase and send to you.
  • Practice self care: Cancer is tough. Go easy on yourself. Have a spa day, use bath bombs, get a massage, try reiki or acupuncture, do yoga, practice meditating…do something just for you each and every day. It is important to have things to look forward to, so maybe schedule an outing with friends, or a day at the beach; things to get you out of the house and into the world. Remember, you are sick, not dead. Life is for the living.
Rahul Singh, MD - Learn Look Locate Medical Advisor
“Don’t let the cancer define you, instead define what you want to be independent of the cancer.”
Who am I?

I am a board-certified medical oncologist and hematologist, with a personal focus in breast cancer. I am involved with the local breast leadership committee and promoting breast cancer awareness. My goal is to arm people coping with this condition, with knowledge to help bridge the gap in understanding. Knowledge is power and the key to winning the battle with breast cancer.

Learn more

More from Dr. Rahul Singh

Click here for Clinical Trials for Chemotherapy

"Let's walk side by side on this journey."-Rahul Singh, MD

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We are so much more than our hair

You know what I’m still learning in my sixth year of survivorship after breast cancer?
Neither the length nor volume of hair I display defines who I am as a woman—as a wife, daughter, or friend either.

While it was incredibly difficult to relinquish my long blonde hair to the effects of chemotherapy, it wasn’t until I stared back at the barren image in the mirror that I began to see the woman that resided within, the woman that I was becoming.

The sudden loss of our hair can make us feel powerless, no longer able to blend in with the flow of people we encounter throughout our everyday lives. The quicksand of comparison, we thrash to escape.

But then we discover that the real power within us was never in our ability to control our circumstances. Rather, the most authentic power can be found within our own thoughts, within the way we choose to move forward in our respective healing journeys.

While I was excited for each progressing state of hair growth I share here, I also have to share with you that though my hair has regrown a fair amount, I still feel nothing like the me I was before my cancer.

My hair has grown, and so have I. And my relationship with my hair, we have grown apart. My hair isn’t the same, and neither am I. Any prior notion of my hair as my identity is old, and I am new.

Friends, if you are finding yourselves searching for past reflections of yourselves, I invite you to pause.

See the person in the mirror—trying, healing, growing. Have grace for your beautiful self. See the you your friends and family members see. Transform your self talk to words of affirmation; speak to yourself just as you would your best friend.

We are so much more than our hair.