1. Debbie Bajrovic Oncology Pharmacist Mount Hospital Pharmacy

2.  Adjuvant therapy is any treatment given after primary surgery.  Neo-Adjuvant therapy is any treatment given before primary surgery.  Therapy can include: chemotherapy hormonal therapy the targeted drug Trastuzumab (Herceptin) radiation therapy or a combination of treatments

3.  Stage of the cancer (size/position)  Grade of the cancer (how closely the tumour cells resemble normal cells)  Your age  Menopausal status  Whether lymph nodes are effected  HER2 status  Hormone receptor status

4.  Use of anti-cancer (cytotoxic) drugs to destroy cancer cells  Usually administered intravenously as an outpatient  Treatment can take a number of hours  Treatment cycles can be weekly, fortnightly or three weekly depending on the drugs used  There is a rest period between cycles to let your body recover from side effects  A complete course is likely to take 4-6 months

5.  Fluorouracil (5-FU)  Epirubicin (Epi)  Cyclophosphamide (Cyclo)  Docetaxel (Taxotere)  Carboplatin (Carbo)  Doxorubicin (Dox)  Paclitaxel (Taxol)

6.  Trastuzumab (Herceptin) – tests are done to see if you are HER 2 +ve (overexpress HER 2)  If you are HER 2 +ve you will be given Herceptin with your chemotherapy.  Treatment may start immediately with chemotherapy or be delayed a few weeks  When chemotherapy finishes you will continue to have Herceptin for a total of 52 weeks.

7.  Hormonal therapies only work in women whose cancer cells have receptors for oestrogen and/or progesterone on their surface. ER+ or PR+  Hormonal therapy deprives the cancer of the hormone oestrogen which many breast cancers need to grow.  They are given after chemotherapy to reduce the chance of the cancer coming back.  Tamoxifen blocks oestrogen activity in the body  Letrozole(Femara), Exemestane(Aromasin) and Anastrozole(Arimidex) stop the body from making oestrogen  Goserelin (Zoladex)

8.  Patients may be offered a choice of chemotherapy treatments, as different drug combinations can cause different side effects.  Some patients may be offered to go on a clinical trial.  Clinical trials are carried out to compare different types of therapy, to improve effectiveness and reduce side effects.

9.  Chemotherapy drugs are often used in combination. These are called chemotherapy regimens or protocols.  FEC (5-FU, Epirubicin, Cyclophosphamide x 6)  FEC-D(T) (FEC x 3- Docetaxel x 3)  AC-T(H) (Doxorubicin, Cyclo x 4 – Taxol x 4)  TAC (Docetaxel, Doxorubicin, Cyclo x 6)  TCH (Docetaxel, Carboplatin, Herceptin x 6)  TC (Docetaxel, Cyclophosphamide x 4)

10.  Pre-meds are given prior to chemotherapy to help reduce hypersensitivity reactions and side effects.  They are given orally and intravenously starting the day before chemotherapy or just prior to chemotherapy  Antiemetic's, steroids, antihistamines and pain killers are used.  Mostly to prevent nausea, fluid retention and allergy  They can cause headaches and constipation

11.  Dexamethasone – steroid used to prevent nausea and fluid retention. Given IV just prior to chemotherapy and orally up to three days after. Sometimes taken twice a day starting the day before chemotherapy  Kytril – (Granisetron) given IV just prior to chemotherapy and orally in the morning on days 2 and 3  Phenergan – (Promethazine) given IV just prior to chemotherapy to help prevent an allergic reaction  Panadol – (Paracetamol) for pain and fever

12.  Maxolon – (Metoclopramide, 10mg) used for breakthrough nausea and vomiting. 1-2 tablets up to 4-6 hourly.  Stemetil – (Prochlorperazine, 10mg) 1 tablet every 4 to 6 hours for breakthrough  Stemetil Suppositories – (Prochlorperazine) 25mg rectally every 12 hours.  Ativan – (Lorazepam, 1mg) – 1 tablet placed under the tongue every 4 to 6 hours if needed for breakthrough nausea.

13.  Neutropenia - reduced numbers of white blood cells which can lower resistance to infection - can begin 7 days after treatment and reaches its lowest point 10-14 days after chemotherapy. - WBC usually increase steadily and return to normal before your next cycle. - Contact your doctor if your temperature goes above 38 C or if you suddenly feel unwell o Neulasta – Injection given 24 hours after chemotherapy which stimulates the level of white blood cells (neutrophils). This can allow frequent dosing of chemotherapy and diminish tumour regrowth.

14.  Bruising or bleeding – reduced numbers of platelets which help the blood to clot - contact your doctor if you have unexplained bruising or bleeding such as nosebleeds or bleeding gums  Anaemia – low red blood cell count - may make you feel tired or breathless

15.  Nausea or vomiting  Diarrhoea/Constipation  Tiredness or fatigue  Hair Loss – usually starts 2 -3 weeks after you start your chemotherapy. Thinning of the eyelashes, eyebrows and other body hair may also occur. Hair loss is temporary.  Sore mouth and ulcers – your mouth may become sore or dry. Drink plenty of fluids, clean teeth regularly with a soft brush, floss daily. Use mouthwashes regularly (half a teaspoon of salt or bicarbonate of soda in a glass of water) Cryotherapy

16.  Taste changes  Irritation of the bladder – cyclophosphamide  Pink urine – Doxorubicin/Epirubicin  Skin changes  Sensitivity to the sun – use sunscreen/hat  Fluid retention  Nail changes  Allergic reactions  Pain in joints or muscles  Numbness or tingling in hands and feet

17.  Flu-like symptoms  Diarrhoea  Headaches  An allergic reaction  Cardiotoxicity – usually mild and reversible

18.  Hot flushes  Vaginal dryness or itching  Loss of libido  Psychological effects  Joint aches or pains