What Are The Different Types of Chemotherapy for Breast Cancer?

Chemotherapy is one of the most common types of treatment used for breast cancer. Chemotherapy is a type of anti-cancer medication that destroys cancer cells. 

Not all people with breast cancer need treatment with chemotherapy, but it’s commonly recommended to be used in early stage breast cancer, invasive breast cancer, and advanced (or metastatic) breast cancer. 

The discovery of chemotherapy many decades ago has revolutionized cancer treatment. As time has progressed, the goals of treatment with chemotherapy have also evolved. Today, chemotherapy aims to raise the chance of a cure, help people live longer, lower the risk of breast cancer coming back, and reduce any symptoms caused by breast cancer. 

In this article, we’ll discuss how chemotherapies work, which ones are used for breast cancer, and how they’re classified. 

Why are chemotherapies divided into different classes?

Chemotherapies are divided into different classes based on how they affect the DNA (deoxyribonucleic acid) in our cells. Disruption — or harming — the DNA of cancer cells causes them to die and prevents them from growing.

In many cases, a combination of two or more chemotherapy medications — or a chemotherapy regimen — will be used. A combination of medications is usually recommended to treat breast cancer because they affect DNA differently. A combination can attack breast cancer in different ways, raising the chance for a successful treatment. 

What are some common chemotherapy combinations used in breast cancer?

Chemotherapy regimens usually have acronyms to help simplify what they’re called. They can also include other medications like HER2 target therapy, discussed below. A few examples of some common breast cancer chemotherapy regimens are:

• AC → T: Doxorubicin and cyclophosphamide followed by paclitaxel

• AC → T: Doxorubicin and cyclophosphamide followed by docetaxel

• AC → THP: Doxorubicin and cyclophosphamide followed by paclitaxel, trastuzumab, and pertuzumab

• TC: Docetaxel and cyclophosphamide

• TAC: Docetaxel, doxorubicin, and cyclophosphamide

• CMF: Cyclophosphamide, methotrexate, and fluorouracil

• TCHP: Docetaxel, carboplatin, trastuzumab, and pertuzumab

These acronyms consist of the first letter of each medication’s name in the regimen, but it varies if the first letter refers to the medication’s brand or generic name. For example — in the TC regimen — the letter T refers to Taxotere, which is the brand name of docetaxel. The C refers to cyclophosphamide. 

These medications are discussed individually below. 

What else can treat breast cancer besides chemotherapy?

There are many types of treatments used for fighting breast cancer. These can be used in addition to — or in place of — chemotherapy. Oftentimes, a combination or sequence of the following treatments may be recommended.

• Surgery: Surgery to remove a tumor or abnormal cells is usually a part of the treatment strategy for most people with invasive breast cancer. There are different types of  surgery for breast cancer, such as a lumpectomy, to remove part of the breast, or a mastectomy, which removes the entire breast.

• Radiation therapy: Radiation therapy uses energy from x-rays, gamma rays, and other sources to shrink tumors and kill cancer cells. This can be given before or after surgery and in combination with chemotherapy.

• HER2 targeted therapy: HER2 is a protein that might be present on some breast cancer cells and can cause breast cancer to grow. When this protein is present on breast cancer cells, it’s called HER2-positive breast cancer. Medications that block HER2 protein can help stop breast cancer growth. 

• Endocrine therapy: Breast cancer can grow from hormones like estrogen and progesterone. Endocrine therapy — also known as hormonal therapy — can lower the amounts of these hormones in the body and is used to prevent and treat breast cancer.

• Other targeted therapies: Other therapies can include medications that target specific receptors that are present on the surface of breast cancer cells. This can include CDK4/6 inhibitors, PARP inhibitors, mTOR inhibitors, PIK3CA inhibitors, and immunotherapy. Some of these therapies are available as medications that can be taken by mouth.

In the following sections, we will discuss the different types of chemotherapies, how often they are given, and what side effects you can expect from each class. 

What is an anthracycline?

An anthracycline is a type of chemotherapy that attacks enzymes (proteins) inside of cancer cells’ DNA which helps them divide and grow. Anthracyclines used in breast cancer treatment include doxorubicin, liposomal doxorubicin, and epirubicin. These anthracyclines are bright red in color and may cause temporary discoloration of urine and bodily fluids.

A side effect of all anthracyclines is that they may cause a type of permanent heart damage, called cardiomyopathy. Because of this, there is a limit to how much anthracycline a person can receive in their lifetime. People receiving treatment with anthracyclines should have their heart function monitored with an echocardiogram or a MUGA scan, a special type of heart imaging technique.

Doxorubicin

Doxorubicin (Adriamycin) is used in both early-stage and advanced-stage breast cancer. Doxorubicin is often given in combination with cyclophosphamide for breast cancer in a chemotherapy regimen called AC. This is usually given as an intravenous (IV) infusion every 2 to 3 weeks for 4 cycles (rounds of treatment). 

Liposomal doxorubicin 

Liposomal doxorubicin (Doxil) is a different formulation (type) of doxorubicin. It’s actually doxorubicin that has been packaged into a fatty sphere called a liposome. This formulation of doxorubicin may last longer than doxorubicin. It’s given as an IV infusion typically every 3 to 4 weeks and is used mostly in metastatic breast cancer. 

It works similarly to doxorubicin, but it’s less likely to cause side effects like heart damage and hair loss. This may be beneficial for people who have already received chemotherapy previously.

Epirubicin 

Epirubicin (Ellence) is given as an IV infusion about every 3 weeks and is used in both early-stage and advanced-stage breast cancers. It’s also given in combination with cyclophosphamide in a chemotherapy regimen called EC. 

Epirubicin works similarly to doxorubicin in breast cancer and may have fewer heart-damaging side effects than doxorubicin. While epirubicin is FDA-approved in the U.S., it’s not used as commonly as doxorubicin.

What is an alkylating agent?

An alkylating agent is a type of chemotherapy that causes damage to DNA in cancer cells to stop them from making more copies of themselves. This is the oldest type of chemotherapy, and ones used to treat breast cancer include medications like carboplatin and cyclophosphamide.

Carboplatin

Carboplatin (Paraplatin) is given as an IV infusion, usually to treat advanced-stage breast cancer. Carboplatin is often given once every 3 weeks in combination with trastuzumab and either paclitaxel or docetaxel — a chemotherapy regimen known as TCH — for HER2-positive breast cancer.

Cyclophosphamide

Cyclophosphamide (Cytoxan) is given as an IV infusion or it can be taken as a capsule by mouth. It’s a commonly used chemotherapy given in combination with an anthracycline or a taxane — like docetaxel — for early-stage and advanced-stage breast cancers. It’s most often given every 2 to 3 weeks. Nausea and vomiting can be significant with cyclophosphamide.

What is an antimetabolite?

An antimetabolite is a type of chemotherapy that works by disrupting the normal metabolism of cells, preventing them from growing. Common antimetabolites used in breast cancer include capecitabine, fluorouracil, gemcitabine, and methotrexate.

Capecitabine

Capecitabine (Xeloda) is a pill taken by mouth. It can be used after surgery or in advanced- stage or metastatic breast cancer that has stopped responding to other chemotherapies like paclitaxel and doxorubicin. Capecitabine is in an inactive form when it’s taken by mouth — the body converts it into the active form called fluorouracil. 

Some people prefer to take an oral chemotherapy because this can be taken at home and does not require receiving an IV infusion of fluorouracil at an infusion center. Capecitabine can cause more diarrhea than IV fluorouracil.

Fluorouracil 

Fluorouracil (Adrucil) is given as an IV infusion. It’s used in both early-stage and advanced-stage breast cancer. Fluorouracil can cause hand-foot syndrome, a red, swollen rash that can appear on the palms of the hands and soles of the feet.

Gemcitabine 

Gemcitabine (Gemzar) is given as an IV infusion. It’s most commonly used in advanced-stage breast cancer, including metastatic breast cancer. Gemcitabine is often used by itself, especially in people who have already received previous chemotherapy, since it does not have as severe of side effects as taxanes and anthracyclines.

Methotrexate

Methotrexate (Trexall) is given as an IV infusion in breast cancer. It’s used in early-stage and advanced-stage breast cancer and most commonly combined with cyclophosphamide and fluorouracil in a chemotherapy regimen called CMF. Since methotrexate is given in higher doses in breast cancer, it’s given as an IV infusion — instead of by mouth, as it would be for other health conditions like rheumatoid arthritis.

What is a microtubule inhibitor?

All cells in the body divide in order to grow, including cancer cells. A microtubule inhibitor stops cancer growth by stopping cells from dividing into two or more cells. Microtubule inhibitors commonly used in the treatment of breast cancer include docetaxel, paclitaxel, eribulin, and vinorelbine. Docetaxel and paclitaxel are also known as taxanes. 

A common side effect of all microtubule inhibitors is nerve damage, also known as peripheral neuropathy. This is commonly felt as a tingling or burning sensation, numbness, or pain in the fingers, arms, feet, or legs.

Docetaxel 

Docetaxel (Taxotere) is given as an IV infusion, usually every 3 weeks. It can be used in both early-stage breast cancer and advanced-stage breast cancer. Docetaxel may be chosen over paclitaxel in some chemotherapy regimens based on side effects and the stage of breast cancer being treated.

Paclitaxel

Paclitaxel (Taxol) is given as an IV infusion. It’s often given weekly for up to 12 cycles following the chemotherapy regimen AC. Paclitaxel can cause an infusion reaction. and most people receive certain medications — such as diphenhydramine (Benadryl), dexamethasone, and famotidine (Pepcid) — prior to their infusion to prevent this reaction. It can be used in both early- and advanced-stage breast cancer.

Protein-bound paclitaxel

Protein-bound paclitaxel, also called nab-paclitaxel (Abraxane), is given as an IV infusion. This is a slightly different formulation of paclitaxel where the medication is bound to a protein called albumin. This may make it easier to tolerate its side effects and require fewer pre-medications than paclitaxel. Protein-bound paclitaxel is typically used in advanced-stage breast cancer.

Eribulin

Eribulin (Halaven) is given as an IV infusion, usually once a week for 2 weeks, followed by 1 week off, but treatment schedules can vary. It’s more commonly used in metastatic breast cancer that has stopped responding to other chemotherapy.

Vinorelbine

Vinorelbine (Navelbine) is given as an IV infusion in advanced-stage or metastatic breast cancer. It’s often given by itself once a week, but dosing schedules can vary.

How often is chemotherapy given for breast cancer?

Chemotherapy for breast cancer is given in cycles, usually 2 to 3 weeks long, with a short break in between. This gives the body time to recover after receiving chemotherapy. Some chemotherapy is only given on one day per cycle, while others are given on multiple days per cycle. For example, gemcitabine is often given on day 1, day 8, and day 15 of an overall 28-day treatment cycle (or weekly for 3 weeks in a row, with 1 week off).

A chemotherapy schedule depends on the type of chemotherapy medications given. Chemotherapy is usually given over 3 to 6 months, or longer in some cases, depending on the type and stage of breast cancer. If you experience bothersome side effects or the treatment is no longer working, you may need to switch treatment to a different chemotherapy or therapy option.

What are some common side effects of chemotherapy used in breast cancer?

Chemotherapy attacks cancer cells, but it can also attack healthy cells in your hair and gut. Chemotherapy side effects depend on the individual, the type of chemotherapy, the dosage and schedule, and the chemotherapy regimen being used. 

In addition to some of the side effects mentioned above, chemotherapy used in breast cancer can cause the following more common side effects:

• Hair loss

• Nail changes

• Mouth sores

• Loss of appetite

• Weight changes

• Nausea and vomiting

• Diarrhea

• Increased chance of infection

• Easy bruising or bleeding

• Fatigue

Chemotherapy effects can be bothersome, but sometimes necessary to receive effective treatment. Thankfully, however, there are other medications and strategies that can be used to help manage certain side effects. If you’re receiving chemotherapy and you experience a bothersome side effect, make sure to mention it to your cancer specialist so they can help manage it. 

If side effects are too bothersome or cannot be tolerated, your chemotherapy regimen may be altered, paused, or completely stopped. 

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Written by:

Sonja Jacobsen, PharmD, BCPS, BCOP

Sonja Jacobsen, PharmD, BCPS, BCOP,  is a clinical oncology pharmacy specialist currently practicing in Seattle. She has been practicing as a pharmacist since 2015 and is licensed to practice in Washington state and North Carolina.

Edited by:

Joshua Murdock, PharmD, BCBBS

Joshua Murdock, PharmD, BCBBS, is a licensed pharmacist in Arizona, Colorado, and Rhode Island. He has worked in the pharmacy industry for more than 10 years and currently serves as a pharmacy editor for GoodRx.

Reviewed by:

Emmeline C. Academia, PharmD, BCOP

Emmeline C. Academia, PharmD, BCOP, has been a practicing clinical pharmacist in adult oncology since 2020. She is a clinical pharmacy specialist in oncology at Beth Israel Deaconess Medical Center, in Boston.

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