If a biopsy shows that you have breast cancer, in addition to the shock and emotional turmoil, a thousand questions go through your mind.

“If a surgeon said that he or she took everything out, so why do you need chemotherapy?” “What are your chances, are you going to die from cancer?”

“My friend only needed to take a pill, why are you not getting that?”

Not everyone diagnosed with breast cancer is treated the same because no two tumors are alike. Even after the lump in the breast is removed surgically, there is a risk of cancer growing back in the same breast or spreading to other organs, a process called metastasis.

The risk of metastasis is based on a number of factors, Age, menopause, the stage of the cancer and characteristics of the tumor cells (grade, hormone receptors called ER and PR, and Her-2) all determine the risk of relapse or metastasis.

Age:

In general, young women tend to have more aggressive tumors and are more often treated with chemotherapy than older women.

Stage:

Breast cancer is staged from Stage 0 to Stage IV; Stage 0 is pre-cancerous and is also known as carcinoma in situ (DCIS or LCIS). Stage 0 cancer does not metastasize and does not require chemotherapy.

Stage I is a small tumour (<2cm) confined to the breast; when the tumour has spread to the lymph nodes or if the tumour is >2cm it is Stage II.

Stage III includes tumours that have spread to lymph nodes in the neck, have affected more than 4 lymph nodes, or has spread to the skin and chest wall. When cancer has metastasized to other organs (commonly to the bones, lungs or liver), it is Stage IV.

The higher the stage, the higher your risk is of relapsing; chemotherapy, hormonal therapy or both are recommended to reduce that risk.

Tumour Characteristics:

Certain features on the cancer cells can predict the aggressiveness of the cancer. Cancer cells are graded from I to III, grade I being the least aggressive and grade III being the most.

The tumour cells are also tested for hormone receptors on the surface of cancer cells, called ER and PR (Estrogen and Progesterone).

Tumour cells are also checked for a protein called Her-2 positive.

About 25-30 per cent of all breast cancers are Her-2 positive. Her-2 positive patients are treated with drugs that target theHer-2 protein, such as Herceptin and Perjeta, in addition to chemotherapy.

Who Needs Chemotherapy?

Even if the visible tumour is removed surgically, you may have cancer cells floating around in your system that can deposit in different parts of the body.

This can happen a few months to several years later, producing metastasis. Research has shown that this risk can be reduced by giving chemotherapy for a few months.

In addition, hormonal therapy and Herceptin are used in appropriate patients.

After surgery, your surgeon will refer you to a Medical Oncologist, who will then determine the kind of treatment you may need. Women who have very early stage breast cancer may not need any treatment and should be observed periodically.

Most women with ER and PR positive tumours are treated with Tamoxifen (before menopause), or Arimidex (Anastrazole) or Femara (Letrozole) (after menopause).

In addition, your medical oncologist may advise you to get chemotherapy based on the other factors mentioned above. The most commonly used chemotherapy drugs are Adriamycin, Cytoxan, Paclitaxel (Taxol), Docetaxel (Taxotere), and 5 Fluorouracil (5 FU). The type of chemotherapy and duration used are also based on the risk of metastasis.

Chemotherapy is given for approximately four to six months, starting about 3 to 4 weeks after surgery. Chemotherapy is often administered as an intravenous infusion. To minimise damage to the veins and to ensure proper administration, a device called a port-a-cath can be inserted below the collarbone. This is temporary and can be removed after treatment is completed.

Side Effects

Chemotherapy can cause nausea, fatigue, vomiting, hair loss, mouth sores, low blood counts and numbness in the extremities.

These are all reversible and improve once treatment is discontinued. With the use of newer medications, nausea and vomiting can be prevented considerably.