An Abbreviated History Of Adjuvant Systemic Therapy
The initial approach to therapy for breast cancer was based on the premise that the disease metastasized via locoregional spread in an orderly fashion, and thus could be cured with aggressive surgery. The radical mastectomy was thus the standard surgical procedure for breast cancer in the early 20th century . Randomized trials subsequently showed no benefit from radical mastectomy compared with less aggressive surgical procedures, and demonstrated that distant recurrence remained a major clinical problem irrespective of the primary surgical therapy .
What Is This Treatment
AC-PACL is the code name of your breast cancer treatment regimen. A regimen is a combination of medications to treat cancer.
This regimen name is made up of 1 or more letters from the names of the 3 medications in your treatment. This regimen name also has letters that describe the dose or other information about how the medication is given.
Here are the names of the medications in this regimen and what the other letters mean:
AC = doxorubicin and Cyclophosphamide
PACL = paclitaxel
DD = dose dense, meaning treatment is given every 2 weeks. Each 2-week period is called a cycle.
For most people, treatment lasts 16 weeks. The treatment is divided into 8 cycles. Each cycle is 2 weeks long.
Here is a picture of the schedule for AC-PACL treatment:
During each 2-week cycle, you will have AC or PACL treatment on day 1 at the hospital.
Each cycle looks like this:
| Day 1 |
| No AC or PACL Treatment |
Do This While On Treatment
- DO tell your healthcare team about any other medical conditions that you have such as heart, liver or kidney problems, or any allergies.
- DO check with your healthcare team before getting any vaccinations, surgery, dental work or other medical procedures.
- DO drink plenty of fluids and pee often for 2 or 3 days after your AC treatment to prevent bladder irritation. It is normal for your urine to be red for up to 2 days after your AC treatment. Tell your healthcare team if your pee stays red for more than 2 days.
- DO talk to your healthcare team about your risk of getting other cancers and heart problems after this treatment.
- DO consider asking someone to drive you to and from the hospital on your treatment days. You may feel drowsy or dizzy after your treatment.
- DO tell your healthcare team if you have any new pain, numbness or tingling of your hands or feet. This is especially important if you are having trouble doing tasks or if you have severe pain or numbness.
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How Chemotherapy Is Used
Doctors use chemotherapy in several ways to treat to treat all stages of breast cancer. Whether or not a doctor recommends chemotherapy for you depends on the breast cancer’s characteristics, your health history, and your personal preferences.
Doctors call chemotherapy given after surgery adjuvant chemotherapy. Chemotherapy is given after surgery to destroy any cancer cells that may have been left behind or may have travelled to other places in the body. These single cells or groups of two or three cells are very small and don’t appear on imaging tests. Chemotherapy after surgery reduces the risk of the cancer coming back, called recurrence by doctors.
Doctors dont recommend chemotherapy after surgery for everyone diagnosed with early-stage breast cancer, except in the following situations:
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If there are cancer cells in the lymph nodes near the affected breast, doctors may recommend chemotherapy.
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If the cancer has characteristics that make it more aggressive, such as being hormone receptor-negative or HER2-positive, doctors usually recommend chemotherapy.
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If youre a pre-menopausal woman, your doctor is more likely to recommend chemotherapy because breast cancer in pre-menopausal women tends to be more aggressive.
Doctors call chemotherapy given before surgery neoadjuvant chemotherapy. Chemotherapy is given before surgery to shrink large cancers, which may:
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breast cancers that have spread to the lymph nodes
Side Effects Of Breast Cancer Chemotherapy
Chemotherapy usually works by attacking rapidly dividing cells. This means that chemotherapy can harm not only cancer cells but also healthy cells that are dividing rapidly, like the ones that cause your hair to grow.
Whether you have side effects from breast cancer chemotherapy will depend on the details of your treatment plan. The care teams at MSK are committed to helping you feel your best during and after treatment. During treatment, well watch carefully for your reaction to the drugs and adjust the drugs or dose as necessary. Well also continue to monitor you for possible long-term effects after your treatment ends.
We offer a variety of other specialized services to support you during your treatment. Many MSK patients find that our Integrative Medicine Service can be a valuable part of their treatment plan. Programs include massage, acupuncture, hypnotherapy, meditation, visualization, music therapy, and nutritional counseling.
One side effect of chemotherapy can be hair loss. MSK offers scalp cooling to help minimize hair loss. Learn more about scalp cooling, or ask your care team for more information.
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Do I Need Genetic Counseling And Testing
Your doctor may recommend that you see a genetic counselor. Thats someone who talks to you about any history of cancer in your family to find out if you have a higher risk for getting breast cancer. For example, people of Ashkenazi Jewish heritage have a higher risk of inherited genetic changes that may cause breast cancers, including triple-negative breast cancer. The counselor may recommend that you get a genetic test.
If you have a higher risk of getting breast cancer, your doctor may talk about ways to manage your risk. You may also have a higher risk of getting other cancers such as ovarian cancer, and your family may have a higher risk. Thats something you would talk with the genetic counselor about.
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What Is Act Chemotherapy Treatment
ACT treatment for breast cancer is a combination of drugs that when used together can work effectively in the fight with the beast that is cancer. This chemo cocktail lowers your bone marrows ability to make blood cells, so your oncologist may prescribe an injectable medication to increase your white blood cell count.
The Doxorubicin part is a vein vesicant and will cause tissue damage if it somehow leaks from the vein. Your oncologist may order you a PICC line to be installed this is to protect the veins and tissue from damage. While uncomfortable when first installed, a PICC line makes the rest of your chemo treatments a breeze. Doxorubicin is red, and is often referred to as the red devil. Its very strong and will turn your urine a reddish color after chemo .
You will need to go in for labs to check your blood work to make sure you are healthy enough to handle another round of chemo. This will be done the day before chemo or right before chemo, and if something doesnt look stellar, then your chemo may be rearranged to make sure you are well enough. This is done with each round.
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For Metastatic Breast Cancer
Chemo can be used as the main treatment for women whose cancer has spread outside the breast and underarm area to distant organs like the liver or lungs. Chemo can be given either when breast cancer is diagnosed or after initial treatments. The length of treatment depends on how well the chemo is working and how well you tolerate it.
What Are The Side Effects Of Ac For Breast Cancer
Common side effects of combination Adriamycin and cyclophosphamide treatment include:
- Bladder irritation, pink or red urine
- Diarrhea or constipation
- Adriamycin for injection. FDA
- Doxorubicin Medscape.com
- Rahman AM, Yusuf SW, Ewer MS. Anthracycline-induced cardiotoxicity and the cardiac-sparing effect of liposomal formulation. Int J Nanomedicine. 2007 2:567583.
- Rheingold SR, Neugut AI, Meadows AT. Therapy-Related Secondary Cancers. In: Kufe DW, Pollock RE, Weichselbaum RR, et al., editors. Holland-Frei Cancer Medicine. 6th edition. Hamilton : BC Decker 2003. Available from:
- Doxorubicin. Drugs.com Oct 7, 2019.
- Cyclophosphamide. Drugs.com Oct 20, 2019,
- Hortobagyi GN, Buzdar AU, Marcus CE, Smith TL. Immediate and long-term toxicity of adjuvant chemotherapy regimens containing doxorubicin in trials at M.D. Anderson Hospital and Tumor Institute. NCI Monogr. 1986 :105-9.
- Fujii T, Le Du F, Xiao L, et al. Effectiveness of an Adjuvant Chemotherapy Regimen for Early-Stage Breast Cancer: A Systematic Review and Network Meta-analysis. JAMA Oncol. 2015 1:13111318. doi:10.1001/jamaoncol.2015.3062
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Second Generation Chemotherapy Regimens
5-Flourouracil, epirubicin , and cyclophosphamide
After randomized trials demonstrated a doseresponse relationship for epirubicin in metastatic breast cancer , the FASG05 compared adjuvant fluorouracil and cyclophosphamide with epirubicin given at 50 mg/m2 or 100 mg/m2 every 21 days for six cycles . After 5 years of follow-up, FEC100 showed improved DFS and OS compared to FEC50 .
Cyclophosphamide, doxorubicin, and 5-fluorouracil
CAF is an acronym that is used to describe regimens in which cyclophosphamide is administered orally for 14 days and doxorubicin and 5-fluorouracil are given on days 1 and 8 every 28 days for six cycles, whereas FAC is an acronym used to describe a regimen in which all of these agents are given IV every 3 weeks for six cycles. The SWOG-8814/INT-0100 trial randomized postmenopausal women with hormone-receptor positive, node-positive breast cancer to CAF plus tamoxifen versus tamoxifen alone. DFS was superior for CAF plus tamoxifen , but OS was only marginally improved . The EBCTCG meta-analysis found that breast cancer mortality rates were reduced more with FAC for six cycles than AC for four cycles or CMF for six cycles , and that FAC or FEC combinations were more effective in reducing breast cancer mortality compared to CMF .
Sequential doxorubicin/cyclophosphamide followed by paclitaxel
Sequential epirubicin followed by CMF
Docetaxel plus cyclophosphamide
Considering Complementary And Alternative Methods
You may hear about alternative or complementary methods that your doctor hasnt mentioned to treat your cancer or relieve symptoms. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.
Complementary methods refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctors medical treatment. Although some of these methods might be helpful in relieving symptoms or helping you feel better, many have not been proven to work. Some might even be harmful.
Be sure to talk to your cancer care team about any method you are thinking about using. They can help you learn what is known about the method, which can help you make an informed decision.
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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 .
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.
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What Happens Before Chemotherapy For Breast Cancer
A few days before your chemotherapy treatment, youll have blood tests. The blood tests tell your oncologist and pharmacist how to tailor your treatment based on your laboratory values and body mass index .
You may receive chemotherapy through a large, sturdy tube called a central venous catheter . If your healthcare provider recommends a CVC, it will be surgically implanted before treatment. It stays in place until you finish chemotherapy. Types of CVCs include:
- Central line: Long, plastic tube inserted near your heart or in a neck vein.
- Peripherally inserted central catheter : A central line that goes in through an arm vein.
- Port-a-cath : A small, implantable chamber where your nurse gives drug injections.
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Side Effects Of Taxol Treatment
You will not be as nauseous with this part of the chemo trio, but Paclitaxel calls for a whole new set of pills to take. Taxol can cause severe allergic reactions, so to limit this, I had to take 1-10mg tablet of Zyrtec one hour before chemo, 2-20mg tablets of Famotidine one hour before chemo, and 5-4mg tablets of Decadron the night before and 5 more two hours before chemo. The Decadron is a steroid so a word of warning, you will be UP the night before chemo these days. I really had a tough time sleeping when I took Decadron.
Chemotherapy For Breast Cancer
Chemotherapy uses anti-cancer drugs that may be given intravenously or by mouth. The drugs travel through the bloodstream to reach cancer cells in most parts of the body. Sometimes, if cancer spreads to the spinal fluid, which surrounds and cushions the brain and spinal cord, chemo may be given directly into in this area .
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Immunohistochemistry And Molecular Classification
All pathologic specimens were reviewed by two experienced pathologists who determined the status of ER, PgR, and HER2 using immunohistochemical techniques. According to the Allred scoring system, ER and PgR negativity was defined as a total score from 0-2 by IHC using antibodies to the ER and PgR . According to National Comprehensive Cancer Network guidelines, HER2 was assessed using IHC techniques and/or fluorescence in situ hybridization . IHC grades 0 and 1 were defined as a negative result for HER2, and the lack of HER2 amplification was confirmed by FISH if HER2 was rated 2+ by IHC. Triple negativity was defined as a lack of expression of ER, PgR, and HER2. The HER2+ subtype was defined as HER2-positive with ER- and PR-negative, while hormone receptor-positive was defined as ER- and/or PR-positive, regardless of HER2-positivity subtypes. Ki-67 growth fractions and p53 status were assessed using antibodies: Ki-67 , and p53 . The percentage of positive nuclei stained for Ki-67 was calculated for each section based on approximately 1,000 carcinoma cell nuclei. High proliferative index was defined as 50% or more stained nuclei. Immunoreactivity of p53 was defined as greater than 5% of cells having distinct nuclear staining.
Effects Of Giving Ac Chemotherapy
While the drug cyclophosphamide is being injected, you may feel hot or flushed and slightly dizzy, and have an itchy nose or a metallic taste in your mouth. These feelings usually go away when the injection is finished, but tell your chemotherapy nurse if you experience any of them. Some people find sucking a boiled sweet helps.
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What Are The Side Effects Of This Treatment
The following table lists side effects that you may have when getting AC or PACL treatment. The table is set up to list the most common side effects first and the least common last. You may not have all of the side effects listed and you may have some that are not listed.
Read over the side effect table so that you know what to look for and when to get help. Keep the link to this page during your treatment so that you can refer to it if you need to.
Side effect and what to do
When to contact healthcare team
Who Might Be Offered Ac Chemotherapy
AC chemotherapy can be used to treat primary breast cancer breast cancer that hasnt spread beyond the breast or the lymph nodes under the arm. Sometimes its used in combination with other anti-cancer drugs. Chemotherapy is given to reduce the risk of breast cancer returning or spreading.
AC chemotherapy may be given before surgery, known as neo-adjuvant treatment , or after surgery, known as adjuvant treatment.
It may also be given to people with:
- local recurrence breast cancer that has come back in the chest/breast area or in the skin near the original site or scar, but has not spread to other parts of the body
- locally advanced breast cancer breast cancer that has come back and has spread to the tissues and lymph nodes around the chest, neck and under the breastbone
- secondary breast cancer breast cancer that has spread to other parts of the body
Recommended Reading: Metastatic Breast Cancer Treatment Guidelines
Feeling Unwell Or Tired
Many women do not feel as healthy after chemo as they did before. There is often a residual feeling of body pain or achiness and a mild loss of physical functioning. These changes may be very subtle and happen slowly over time.
Fatigue is another common problem for women who have received chemo. This may last a few months up to several years. It can often be helped, so its important to let your doctor or nurse know about it. Exercise, naps, and conserving energy may be recommended. If you have sleep problems, they can be treated. Sometimes fatigue can be a sign of depression, which may be helped by counseling and/or medicines.