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Chemotherapy (chemo) is treatment with cancer-killing drugs that may be given intravenously (injected into your vein) or by mouth. The drugs travel through the bloodstream to reach cancer cells in most parts of the body. Occasionally, chemo might be given directly into the spinal fluid which surrounds the brain and spinal cord.   

When is chemotherapy used?

Not all men with breast cancer will need chemo, but there are several situations in which chemo might be recommended: 

• After surgery (adjuvant chemotherapy): When treatment is given to patients who have no evidence of cancer after surgery, it is called adjuvant therapy. Adjuvant chemo is used to try to kill any cancer cells that might have been left behind or have spread but can't be seen, even on imaging tests. If these cells were allowed to grow, they could form new tumors in other places in the body. Adjuvant chemo can lower the risk of breast cancer coming back. Radiation and hormone therapy can also be used as adjuvant treatments.
• Before surgery (neoadjuvant chemotherapy): Neoadjuvant therapy is like adjuvant therapy, except you get the treatments (or at least start them) before surgery instead of after. Neoadjuvant chemo can be used to try to shrink the tumor so it can be removed with less extensive surgery. Because of this, neoadjuvant chemo is often used to treat cancers that are too big to be removed by surgery at the time of diagnosis (called locally advanced cancers). Also, by giving chemo before the tumor is removed, doctors can better see how the cancer responds to it. If the first set of chemo drugs doesn’t shrink the tumor, your doctor will know that other drugs are needed. It should also kill any cancer cells that have spread but can't be seen. Just like adjuvant chemo, neoadjuvant chemo can lower the risk of breast cancer coming back. In terms of survival and the chances of cancer coming back, there is no difference between getting chemo before or after surgery.
• For advanced breast cancer: Chemo can also be used as the main treatment for men whose cancer has either already spread beyond the breast and underarm area when it is diagnosed, or if it spreads after initial treatments. The length of treatment depends on how well the chemo is working and how well you tolerate treatment.

Sometimes it's not clear if chemotherapy will be helpful. There are tests available, such as Oncotype DX and MammaPrint, that can help determine which men will most likely benefit from chemo after breast surgery. See ?How is Breast Cancer in Men Classified? for more information. 

Which chemotherapy drugs are used for breast cancer?

In most cases (especially as adjuvant or neoadjuvant treatment), chemo is most effective when combinations of drugs are used. Today, doctors use many different combinations, and it's not clear that any single combination is clearly the best.

The most common drugs used for adjuvant and neoadjuvant chemo include:

• Anthracyclines, such as doxorubicin (Adriamycin) and epirubicin (Ellence)
• Taxanes, such as paclitaxel (Taxol) and docetaxel (Taxotere)
• 5-fluorouracil (5-FU)
• Cyclophosphamide (Cytoxan)
• Carboplatin (Paraplatin)

Most often, combinations of 2 or 3 of these drugs are used.

Chemo drugs useful in treating breast cancer that has spread include:

• Taxanes, such as paclitaxel (Taxol), docetaxel (Taxotere), and albumin-bound paclitaxel (Abraxane)
• Anthracyclines (Doxorubicin, pegylated liposomal doxorubicin, and Epirubicin?)
• Platinum agents (cisplatin, carboplatin)
• Vinorelbine (Navelbine)
• Capecitabine (Xeloda)
• Gemcitabine (Gemzar)
• Ixabepilone (Ixempra) Albumin-bound paclitaxel (nab-paclitaxel or Abraxane)
• Eribulin (Halaven)

Although drug combinations are often used to treat early breast cancer, advanced breast cancer more often is treated with single chemo drugs. Still, some combinations, such as paclitaxel plus carboplatin, are commonly used to treat advanced breast cancer.

For cancers that are HER2-positive one or more drugs that target HER2 may be used with chemo. See Targeted Therapy for Breast Cancer in Men for more information about these drugs.

How is chemotherapy given?

Chemo drugs for breast cancer are typically given into a vein (IV), either as an injection over a few minutes or as an infusion over a longer period of time. This can be done in a doctor’s office, chemotherapy clinic, or in a hospital.

Often, a slightly larger and sturdier IV is required in the vein system to administer chemo. They are known as central venous catheters (CVCs), central venous access devices (CVADs), or central lines. They are used to put medicines, blood products, nutrients, or fluids right into your blood. They can also be used to take out blood for testing.

Many different kinds of CVCs are available. The 2 most common types are the port and the PICC line. For breast cancer patients, the central line is typically placed on the opposite side of the breast that had surgery.

Doctors give chemo in cycles, with each period of treatment followed by a rest period. Chemo begins on the first day of each cycle, but the schedule varies depending on the drugs used. For example, with some drugs, the chemo is given only on the first day of the cycle. With others, it is given every day for 14 days, or weekly for 2 weeks. Then, at the end of the cycle, the schedule of chemo repeats to start the next cycle.

Cycles are most often 2 or 3 weeks long, but they vary according to the specific drug or combination of drugs. Some drugs are given more often. Adjuvant and neoadjuvant chemo is often given for a total of 3 to 6 months, depending on what drugs are used. Treatment is often longer for advanced breast cancer, and is based on how well it is working and what side effects you have.

Dose-dense chemotherapy: Doctors have found that giving the cycles of certain chemo agents closer together can lower the chance that the cancer will come back and improve survival in some patients. This usually means giving the same chemo that is normally given, but giving it every 2 weeks instead of every 3 weeks. A drug (growth factor) to help boost the white blood cell count is given after the chemo to make sure the white blood cell count returns to normal in time for the next cycle. This approach can be used for both adjuvant and neoadjuvant chemo. It can lead to more problems with low blood counts, though, so it isn’t for everyone.

Possible side effects of chemotherapy

Chemo drugs attack cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow, the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are likely to be affected by chemo too, which can lead to side effects. Some men have many side effects while other men may have few.

The side effects of chemotherapy depend on the type of drugs, the amount taken, and the length of treatment. Some of the most common possible side effects include:

• Hair loss
• Mouth sores
• Loss of appetite (or increased appetite)
• Nausea and vomiting
• Low blood cell counts

Chemo can affect the blood-forming cells of the bone marrow, which can lead to:

• Increased chance of infections (from low white blood cell counts)
• Easy bruising or bleeding (from low blood platelet counts)
• Fatigue (from low red blood cell counts or other reasons)

These side effects are usually short-term and go away after treatment is finished. Let your cancer care team know if you have any side effects, because there are often ways to lessen them. For example, drugs can be given to help prevent or reduce nausea and vomiting.

Several other side effects are also possible. Some of these are only seen with certain chemotherapy drugs. Ask your cancer care team about the possible side effects of the specific drugs you are getting.

Nerve damage (neuropathy): Many drugs used to treat breast cancer, including the taxanes (docetaxel and paclitaxel), platinum agents (carboplatin, cisplatin), vinorelbine, erubulin, and ixabepilone, can damage nerves outside the brain and spinal cord. This can sometimes lead to symptoms (mainly in the hands and feet) such as numbness, pain, burning or tingling sensations, sensitivity to cold or heat, or weakness. In most cases this goes away once treatment is stopped, but it might last a long time in some men.

Heart damage: Doxorubicin, epirubicin, and some other drugs may cause permanent heart damage (called cardiomyopathy). The risk is highest if the drug is used for a long time or in high doses. Most doctors check your heart function with a test like a MUGA or echocardiogram(an ultrasound of the heart) before starting one of these drugs. They also carefully control the doses and watch for symptoms of heart problems, and may repeat the heart test to monitor heart function during treatment. If the heart function begins to worsen, treatment with these drugs will be temporarily or permanently stopped. Still, in some people, signs of damage might not appear until months or years after treatment stops. Damage from these drugs happens more often if other drugs that can cause heart damage (such as those that target HER2) are used also, so doctors are more cautious when these drugs are used togethe?r.

Hand-foot syndrome: Certain chemo drugs, such as capecitabine and liposomal doxorubicin, can irritate the palms of the hands and the soles of the feet. This is called hand-foot syndrome. Early symptoms include numbness, tingling, and redness. If it gets worse, the hands and feet can become swollen, uncomfortable, or even painful. The skin may blister and peel. There is no specific treatment, although some creams or steroids given before chemo may help. These symptoms gradually get better when the drug is stopped or the dose is lowered. The best way to prevent severe hand-foot syndrome is to tell your doctor when early symptoms come up, so that the drug dose can be changed or other medications can be given .

Chemo brain: There is very little research on chemo brain in men, but many women who are treated for breast cancer report a slight decrease in mental functioning. There may be some long-lasting problems with concentration and memory. Although many women have linked this to chemo, it also has been seen in women who did not get chemo as a part of their treatment. Also, most women do function well after chemotherapy. In studies of chemo brain as a side effect of treatment, the symptoms most often go away within a few years. Even though most research was done in women, there's no reason to expect any differences in men being treated for breast cancer.

Increased risk of leukemia: Very rarely, certain chemo drugs can cause diseases of the bone marrow such as myelodysplastic syndrome or even acute myeloid leukemia, a cancer of white blood cells. When this happens it is usually within 10 years of treatment. For most men though, chemo's benefits of helping to prevent breast cancer from coming back or extending life are likely to far exceed the risk of this serious but rare complication.

Feeling unwell or tired: Many people do not feel as healthy after chemotherapy as they did before. There is often a residual feeling of body pain or achiness and a mild loss of physical functioning. These may be very subtle changes that happen slowly over time.

Fatigue is often another common (but often overlooked) problem for those who have had chemo. This may last up to several years. It can often be helped, so it is important to let your doctor or nurse know about it. Exercise, naps, and conserving energy may be recommended. If there are problems with sleep, these can be treated. Sometimes there is depression, which may be helped by counseling and/or medicines.