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MRI, or magnetic resonance imaging, is able to produce a detailed cross-sectional image of the inside of the body.  It does this using a combination of a magnetic field and radio waves.  There is no radiation involved.
It is most often used:

• to gather more information about an area of suspicion.  A breast MRI can help to accurately identify the size and number of breast lesions or abnormal areas 


• for women with a strong family history of breast cancer


• to monitor for recurrence after treatment for breast cancer.

When you have an MRI you will be asked to lie on your stomach on a special examination table with cushioned openings for your breasts to sit in.  These cushioned openings contain a special coil which helps relay signals for the MRI. 

The examination table is then slowly moved into the MRI machine – a long tube like structure.  The MRI machine makes a loud beeping noise during the procedure, which usually takes up to 45 minutes.  Some people may feel claustrophobic during an MRI.  If this is the case for you, you may be given a mild sedative.

Because an MRI uses magnetic fields, it’s very important you remove anything metal on your body – jewellery, watches, belts etc or tell your doctor if you have any metal parts in your body.  You should also tell your doctor if you are pregnant or suspect you may be pregnant.  

Ultrasounds are frequently used to complement other screening tests. 

They are most often used if an abnormality is seen on a mammogram. In cases such as this, an ultrasound can help to provide further information about the nature of a lump or an area of concern. 

Ultrasounds are also more frequently used on younger women who have denser breast tissue.  Ultrasounds can be more sensitive in picking up abnormalities in dense tissue than a mammogram can.

An ultrasound works by sending high frequency sound waves through your body.  These sound waves are then converted into images on a viewing screen.  The technician simply runs a sound-emitting probe over your breast.  There is no radiation involved and the procedure should not be painful. 

Ultrasounds are frequently used to complement other screening tests. 

They are most often used if an abnormality is seen on a mammogram. In cases such as this, an ultrasound can help to provide further information about the nature of a lump or an area of concern. 

Ultrasounds are also more frequently used on younger women who have denser breast tissue.  Ultrasounds can be more sensitive in picking up abnormalities in dense tissue than a mammogram can.

An ultrasound works by sending high frequency sound waves through your body.  These sound waves are then converted into images on a viewing screen.  The technician simply runs a sound-emitting probe over your breast.  There is no radiation involved and the procedure should not be painful. 

A mammogram is essentially a low dose x-ray which gives a photograph of the breast that doctors can use to identify any abnormalities.

Mammograms are used as:

• a screening tool for healthy women to check for any developing problems in the breast
• a diagnostic tool to get more information about a specific area of concern.

A mammogram is currently the standard way to detect early breast cancer. If breast cancer is detected early, treatment can begin early and a woman has a greater chance of survival. 

Mammograms have been shown to lower the risk of dying from breast cancer by 20 to 30 per cent in women over the age of 50 (World Health Organisation). A new Swedish study has found that mammograms can reduce the risk of dying from breast cancer by 29 per cent in women aged 40 to 49 ((Cancer 29/09/10). Mammograms literally save lives.

What happens during a Mammogram

During a mammogram you will place your breast between the two plates of an x-ray machine (pictured right). The breast is then flattened between these plates while the x-ray is taken. Sometimes, this can feel uncomfortable and for some it might feel slightly painful, but it only lasts a few seconds while the x-ray is taken.

The mammogram x-ray identifies lumps or changes in the breast tissue which may develop into breast cancer over time. A mammogram is a very good way of identifying lumps or changes in the breast which cannot be felt by a woman or her doctor.

Going for a mammogram may be a scary experience, especially as you wait for results or if an abnormality is found. 

You will usually receive the results of your mammogram within two weeks. If you have had a previous mammogram then your past x-rays will be compared with your latest picture to pick up any changes.

A small number of women will be asked to return for a further check up because something of concern has been found.  This could involve a further mammogram, an ultrasound or perhaps a biopsy.  If you are asked to return for further tests, remember that many breast lumps found (up to 9 out of 10) are harmless or benign. For more information see our pages on biopsies and other diagnostic tests. 

Accuracy of mammograms

A mammogram will frequently pick up breast changes, but it is not a 100 per cent accurate. Sometimes a mammogram will suggest a problem is present, when in fact everything is alright.

And sometimes a mammogram will miss developing breast cancer. This is usually because:

• some cancers do not show up on a mammogram especially in younger women with more dense breast tissue

• the radiologist does not identify the cancer

• a rapidly growing cancer may be missed between two-yearly mammogram appointments.

Some clinics in New Zealand use digital mammography in which a digital image is taken of the breast, rather than the more common x-ray film mammography.   Studies have shown that digital images can result in a more accurate identification of breast cancer in some women.  This is because digital images can be manipulated so that images can be examined more closely which is particularly useful when examining mammograms of women with dense breasts.   

 Those who may benefit from a digital mammogram are: 

• women aged under 50

• women with very dense or extremely dense breasts

• pre or peri-menopausal women (women who had a menstrual period with the last 12 months)

Despite the fact that neither digital nor film mammograms are 100 per cent accurate, they are still the most commonly used way to pick up breast cancer early enough to reduce your risk of dying from the disease.

If you are concerned about a lump which may have developed between your two-yearly mammograms, you should consult your doctor immediately.

The BreastScreen Aotearoa programme

BCAC encourages all women aged between 45 and 69 participate in the BreastScreen Aotearoa free screening programme. Under this programme, you are entitled to a free mammogram every two years. Find out more about this programme here.

If you are younger than 45 or older than 69 you can ask your doctor to refer you to a private radiologist. You will have to pay for your mammogram, but if you have medical insurance this may be reimbursed. 

Surgery to remove all or part of your breast as part of breast cancer treatment can have an impact on your sense of self, your body image, and your sexuality. 

Some women find they cope better with these issues after breast reconstruction surgery.  This involves the surgical reconstruction of the breast tissue to create a body shape similar to your pre-surgery shape. However, a reconstructed breast will never look or feel the same as your own breast.

Breast reconstruction surgery is optional and many women never have this surgery. It is an individual choice so take the time to think about this carefully. For many women reconstruction aids recovery and helps them feel better about themselves. However, it is not the right choice for everyone and it may not be appropriate for you.  Discuss your options with your surgeon.

Breast reconstruction can be carried out at the same time as your initial surgery - known as immediate reconstruction.  Alternatively, you may prefer to wait until your cancer treatment is over before you consider reconstructive options – this is known as delayed reconstruction. This may also be the advice of your surgeons and is often the case if your surgeon prefers to wait until you have recovered from chemotherapy and/or radiotherapy before having further surgery.  However, in some parts of New Zealand, there can be long waits for delayed breast reconstruction surgery, so make sure you discuss this issue thoroughly with your surgeon.  

There are different kinds of reconstruction surgery avaialable so think about these carefully and make sure you are happy with your medical team. Some questions you might like to ask your surgeon include:

• what types of reconstructive surgery to you perform?
• how many times have you performed these different procedures?
• have you had special training to perform these types of surgery?
• can I view your album of previous results?

There are three commonly used methods of reconstruction and these are listed below.

• Implants

  This method usually involves two stages. At the first operation a tissue expander is placed under the muscle of the chest wall.  Sometimes it may be  placed under the skin only, rather than the muscle - speak to your surgeon about the option that's best for you.  The tissue expander is expanded over time by an injection of saline.  At a second operation the tissue expander is removed and replaced with a silicone gel implant.  This technique gives good size balance.  As your body changes with time further surgery may be required.

• Latissimus dorsi flap, often with an implant

  Skin and muscle from the back is brought forward onto the chest to reconstruct the breast. Usually a tissue expander and implant is also needed to achieve size and shape match.  This approach often achieves a more natural breast shape. It will leave a scar on the back, your shoulder strength will take some months to recover and overall recovery is longer than implant reconstruction alone.

• Abdominal tissue reconstruction

  There are several techniques for moving skin and fat from your abdomen to reconstruct your breast. The blood supply to that tissue can be left intact - this is called a pedicled TRAM flap. Alternatively, microsurgery is used to re-establish the blood supply -  this is called a free TRAM flap. Often this approach gives enough tissue to enable the surgeon to create a natural breast shape without the need for an implant. However, this kind of surgery is extensive. It can result in weakness and bulging in the abdominal area and has a longer recovery period.

• Further surgery

  Often further surgery is required to achieve a better balance. This may require surgery to the other breast such as a lift or reduction. The reconstructed breast may often require further adjustment as well.

Finally, you may wish to consider reconstruction of a nipple and areola. This surgery is usually many months after the initial breast reconstruction.

Recommendations on breast reconstruction:

Clinicians should follow the recommendations of the New Zealand Guidelines on the Management of Early Breast Cancer on breast reconstruction. These state:

• A woman being prepared for a mastectomy should be informed of the option of breast reconstruction and, if appropriate, should discuss the option with a surgeon trained in reconstructive techniques prior to the surgery.

• The use of immediate or delayed breast reconstruction is an important means of enhancing body image and self-confidence after mastectomy and both options should be available to women in the public and private sectors in New Zealand.

Complementary therapies are techniques that may help you to cope with breast cancer treatment and manage the psychological, social and physical burdens treatment can entail. 

Complementary therapies should not be used as a replacement or alternative to conventional and scientifically proven medicine.

However, if they help you cope with side effects, relieve some symptoms and improve your quality of life then they can be a valuable addition to your treatment programme. You may like to check out Professor Shaun Holt's book, Complementary Therapies for Cancer - What works, what doesn't ... and how to tell the difference (Craig Potton Publishing, 2010) for a guide on complementary techniques.  You can also read BCAC's articles about 2023 research findings on this topic by clicking on the links below:

• Complementary  medicines: what is good and what is bad?

• Integrative medicine in advanced breast cancer treatment – report from the ABC7 conference

Many women like to explore a variety of options, and make their decision about which complementary therapies they will use after researching the options and being fully informed. Two useful websites that you may wish to explore as you embark on your own journey of research and education are:

• The US National Cancer Institute has a section on complementary medicines with research reviews that are updated regularly
• Cancer Research UK also has a section on complementary cancer approaches.

Always check with your doctor before beginning a complementary therapy. Some complementary medicines or supplements can interfere with your anti-cancer medicines. BCAC advises against “alternative medication” as a replacement for conventional medication.  These "alternative" medications have not been scientifically validated or proven to be effective in fighting cancer and could interfere with your conventional treatment programme. 

Some common complementary therapies include:

• Acupuncture
• Massage
• Yoga
• Meditation
• Counselling
• Keeping a journal
• Rongoā Māori
• Music and art therapy
• Prayer

Acupuncture

Acupuncture involves a practitioner inserting very thin needles into your body. Acupuncture is based on traditional Chinese medicine and needles are placed in parts of the body thought to improve the body’s vital energy or ‘Qi’. 

Research has shown that acupuncture may stimulate the nervous system to release natural pain killers. Some studies have shown it may be effective in helping:

• Fatigue
• Nausea and vomiting
• Pain.

Massage

Massage involves manipulating the soft tissue of the body and many people find it relaxing and beneficial for relieving stress. Some studies have shown that it is helpful in relieving:

• Pain
• Fatigue
• Anxiety.

Yoga

Yoga is a form of traditional Indian exercise that focuses on the body and the mind. It involves stretching exercises and may be helpful in:

• Strengthening muscles
• Reducing stress
• Reducing fatigue.

Other forms of exercise can also be beneficial for many women. BCAC member group, the PINC Cancer Rehabilitation Programme, offers exercise programmes that help to strengthen the body and focus the mind following breast cancer treatment.

Meditation, mindfulness and self-compassion

Meditation is a mind exercise that involves focusing on a specific thing so that all extraneous thoughts are put out of the mind.

Meditation has been found to help:

• Reduce stress
• Improve sleep
• Reduce fatigue.

Mindfulness and self-compassion are meditative practices aimed at improving wellbeing by training the mind to adopt thoughts that help us to deal with anxiety and emotions. BCAC member group, Mindfulness Aotearoa, offers training in Mindfulness Based Stress Reduction which research has shown can help to reduce emotional distress, anxiety and fatigue. See their website or contact jan@mindfulnessaotearoa.com - 021 22 77 069.

Some useful American websites to explore are:

• Meditation, Tara Brach
• Self Compassion, Kirsten Neff
• Mindfulness, Meditation, Jack Kornfield.

Counselling

Counselling involves talking to a trained professional about your emotions and behaviours.  Many people may find counselling helps them to:

• Relieve stress
• Focus on the positive
• Deal with negative emotions.

A list of counsellors offering services to those with breast cancer can be found here.

Keeping a journal

This involves writing down an account of the thoughts, feelings and events you experience. It has been shown that this can help to:

• Improve emotional wellbeing
• Improve physical health.

BCAC’s Step by Step support pack includes a journal for recording your thoughts and feelings, with space for writing and drawing. Order your pack here.

Rongoā Māori

Rongoā Māori is traditional Māori healing in which an understanding of the events leading to ill health and its impacts are addressed through a range of culturally bounded responses, including rakau rongoā (native flora herbal preparations), mirimiri (massage) and karakia (prayer).

The Ministry of Health works with Māori traditional healing practitioners to support Rongoā Māori, and currently funds 30 providers across the country to deliver rongoā services. More information can be found here.

Music and art therapy

This involves using music or art to express yourself and your feelings.  For some people this outlet can help to:

• Reduce anxiety
• Improve emotional wellbeing.

BCAC member group Alleviate Ltd offers highly professional and innovative creative arts therapy programmes and one-on-one therapy for women who have been diagnosed with breast cancer.

Prayer

For those who are religious or subscribe to a form of spirituality, prayer can be a useful way to:

• Relieve anxiety
• Enhance emotional wellbeing.

Many breast cancers respond to hormones present in the body, such as oestrogen and progesterone. 

If a cancer is oestrogen receptor positive then it grows faster when oestrogen is present.  If a cancer is progesterone receptor positive, then it grows faster when progesterone is present.

Endocrine therapy (sometimes known as hormone therapy) works by blocking the effects of these hormones so that they are unable to stimulate the cancer cells to grow.

Your pathology report will tell you whether your breast cancer is responsive to oestrogen or progesterone or both. If your breast cancer is hormone receptor positive you may benefit from endocrine therapy.

Endocrine therapy is used to reduce the risk of hormone positive breast cancer from coming back following surgery, radiotherapy and/or chemotherapy. It can be used in both pre- and post-menopausal women, but your menopausal status and whether your cancer was node-positive or node-negative will influence your doctor’s decision about which treatment option is right for you. Endocrine therapy is often taken for a long time. You may need to switch from one option to another as time goes by; your doctor will advise you on this.

There are three general categories of endocrine therapy drugs, which are all taken as tablets.

Aromatase inhibitors

These drugs work by blocking the production of oestrogen in the body and are generally only suitable for post menopausal women. If taken as recommended, aromatase inhibitors have been shown to significantly reduce the risk of breast cancer returning to the same breast or occurring in the opposite breast.

Drugs in this category include anastrozole, letrozole and exemestane. All drugs are taken orally over a long period of time (usually for at least five years).

Side effects of these medicines can include hot flushes, joint and muscle aches, mild nausea, vaginal dryness and reduced bone density, sometimes causing osteoporosis. The potential risk of osteoporosis means that bone density monitoring is recommended while taking aromatase inhibitors.  Most cancer centres in New Zealand now offer regular bone density scans for patients on aromatase inhibitors, but if yours doesn't ask for regular DEXA scans.  

SERMs (Selective Estrogen Receptor Modulators):  

This group of drugs prevents oestrogen from taking hold in cancer cells and so reduces the ability of these cells to grow.

The most commonly prescribed SERM in New Zealand is tamoxifen, a drug that can be used in both pre- and post-menopausal women. Again, this drug will need to be taken orally for up to five years. Recent data has shown benefit from switching post-menopausal women to an aromatase inhibitor following treatment with tamoxifen.

Research (2012) has shown that taking tamoxifen for ten years, rather than five helps to reduce the recurrence of breast cancer and results in better overall survival rates. Find out more here. The 2018 Amercian Society of Clinical Oncology (ASCO) guidelines list the different combinations of tamoxifen and aromatase inhibitor treatments that may be recommended by your doctor depending on your menopausal status, the node status of your original tumour, and other breast cancer recurrence risk factors.

Side effects of tamoxifen include menopausal type effects such as hot flushes, and vaginal dryness. More seriously, occasionally (in fact in only one per cent of cases over five years) some women can experience blood clots and very rarely tamoxifen has resulted in uterine cancer. Any vaginal bleeding should be immediately reported to your doctor.

Oestrogen Receptor Downregulators (ERDs)

Similar to SERMs, these drugs work by blocking the effects of oestrogen in the breast tissue so they starve the cancer cells of the oestrogen they need to grow.

At present there is only one ERD available in New Zealand – Faslodex® (generic name: fulvestrant). It is used to treat hormone-receptor-positive advanced breast cancer in post-menopausal women with disease progresssion following other anti-oestrogen therapy, such as tamoxifen. Fulvestrant may also be used in conjunction with Ibrance® (generic name: palbociclib).

Fulvestrant is given as an injection into a muscle once a month. Side effects are generally minimal, however, they can include discomfort at the injection site, hot flushes, vomiting, nausea, and diarrhoea.

Other endocrine therapy options

In pre-menopausal women most of the oestrogen and progesterone hormones are produced by the ovaries, and to a lesser degree also in the liver and in fat tissue. A different way of lowering the hormone levels in pre-menopausal women is to remove the ovaries with surgery or by chemically blocking the function of the ovaries with drugs known as lutenising hormone releasing hormone (LHRH) blockers, such as goserelin (Zoladex®) or leuproreline (Lucrin®).

Both drugs are given after chemotherapy as a monthly injection into the abdominal wall. They are fully funded. Both options have a similar effect, i.e. they induce a menopause, but the surgical option is irreversible whereas with the injection option, the pre-menopausal hormone levels will return once the injections are ceased. 

These injections may be recommended for pre-menopausal women with hormone receptor positive breast cancer when taking tamoxifen is not advised or could be used as alternative to tamoxifen.

For more information on LHRH medicines see our fertility section on our pages for young women.

Like chemotherapy, targeted therapies are drug therapies, but they are often given over a longer period of time. 

These medicines are different from most chemotherapy drugs because they attack specific elements of the cancer cells and are less likely to harm normal cells.

There are five targeted therapy drugs publicly funded in New Zealand (see below).

Many targeted therapy drugs are given intravenously and you may have a special device called a port-a-cath inserted into your chest wall or a PICC line in your arm to help medical staff give these drugs easily on a regular basis. This will save a nurse having to find a vein in your arm or hand each time you need treatment.

New targeted therapies are being developed all the time and clinical trials are underway to investigate the effectiveness of these newer drugs. See below for information about targeted therapies not yet funded in New Zealand and find out more about access to new medicines here.

Targeted therapies funded in New Zealand

Anti-HER2 therapies

Trastuzumab (brand names Herceptin® or Herzuma®). This drug is used in women with HER2-positive breast cancer and works by blocking the chemical signals that tell this type of cancer cells to grow. Trastuzumab is a monoclonal antibody drug, designed specifically to target and block a particular molecule - in this case, the HER2 protein.

It is given by intravenous infusion over a 12-month period and is now fully subsidised in New Zealand, thanks to a prolonged campaign by BCAC and others.

Side-effects: trastuzumab is usually extremely well tolerated with any side effects being very rare. Very few women may experience flu-like symptoms, but these should become less severe as your treatment programme progresses.

In some cases, trastuzumab can cause heart problems. This can range from very mild heart damage which results in no symptoms to more serious problems and in rare cases heart failure. Your doctor will discuss these issues with you and monitor your heart during your treatment programme. If you experience shortness of breath or heart palpitations let your doctor know immediately.

Click here for more information on the benefits of trastuzumab (Herceptin) and research about its effectiveness.

Biosimilar versions of Herceptin® (trastuzumab) have now been developed as well. These molecules are not identical to Herceptin®, but are designed to perform in the same way. As of November 1st 2023, Pharmac will be funding Herzuma®, a biosimilar trastuzumab.

Pertuzumab (brand name Perjeta®) This monoclonal antibody drug is used in conjunction with trastuzumab in patients with HER2-positive metastatic breast cancer who have not received prior therapies for their metastatic disease (i.e. as a ‘first-line treatment’). It works by inhibiting different proteins that cause HER2-positive breast cancers to grow. Results from the CLEOPATRA clinical trial reported in 2014 showed an extraordinary survival benefit of 15.7 months for patients who received this drug. Pertuzumab is Medsafe registered and publicly funded in New Zealand for many HER2-positive metastatic breast cancer patients. It is not yet funded by Pharmac for use in early breast cancer. The most common side-effects of pertuzumab are diarrhoea, nausea, fatigue and rash.

Click here for a fact sheet on pertuzumab (Perjeta).

Tyrosine kinase inhibitors

Lapatinib (brand name Tykerb®) is a tyrosine kinase inhibitor for the treatment of HER2-positive metastatic breast cancer. This drug is given in pill form and fights HER2-positive breast cancer by attacking the HER2 protein at a different site from trastuzumab.

Lapatinib is funded in New Zealand only for those with HER2-positive metastatic breast cancer who have not already received trastuzumab for their advanced disease (i.e. as a first-line treatment only). However, in other countries lapatinib is approved for later-line use for those whose metastatic breast cancer has progressed on trastuzumab.

Side-effects: The most common side effects of lapatinib are diarrhoea, skin rash, vomiting and fatigue. Dosages can be adjusted and other medicines used to ease these problems. In rare cases lapatinib can result in minor heart damage. 

Click here for a fact sheet on lapatinib (Tykerb).

Antibody-drug conjugates

Trastuzumab emtansine (brand name Kadcyla®) This drug is used in patients with HER2-positive metastatic breast cancer who have received prior trastuzumab and chemotherapy separately or together and either received prior therapy for metastatic disease, or who relapsed within 6 months of completing adjuvant therapy. As it is used after earlier treatments for metastatic disease it is known as a ‘second-line’ strategy. Trastuzumab emtansine is an antibody-conjugate drug that combines a cytotoxin (emtansine) that disrupts cell division, growth and functioning, with trastuzumab. The trastuzumab component targets the emtansine component to the HER2-positive tumours, delivering the toxin directly to the tumour cells and reducing effects on other normal cells in the body. Results from the 2017 international clinical trial EMILIA showed patients receiving trastuzumab emtansine had a median overall survival benefit of 5.8 months (30.9 months vs. 25.1 months) compared to those given the combination of capecitabine and lapatinib. This drug is approved by Medsafe and is publicly funded in New Zealand. Common side effects with trastuzumab emtansine may include tiredness, nausea and muscle/joint pain.

Recent data from the KATHERINE international clinical trial has shown that trastuzumab emtansine can also significantly reduce the risk of recurrence of invasive breast cancer (and death) when given to patients with HER2-positive early breast cancer whose tumours have not responded completely to neo-adjuvant (pre-surgery) chemotherapy and trastuzumab treatment. PHARMAC recently announced that trastuzumab emtansine would be funded for use in some patients with HER2-positive early breast cancer and a high risk of recurrence.

Click here to read a fact sheet on trastuzumab emtansine (Kadcyla).

CDK 4/6 inhibitors

Palbociclib (brand name Ibrance®) is one of a group of medicines called CDK 4/6 inhibitors - others are ribociclib and abemaciclib. Only palbociclib is funded in New Zealand, the other two are not. These drugs work by inhibiting particular enzymes that are needed for tumour cells to divide; they interrupt the ‘cell cycle’ and stop the tumours from growing. They are used for treating hormone receptor-positive, HER2-negative metastatic breast cancer. In New Zealand palbociclib is funded for first-, second- or later-line use in these patients. The PALOMA-3 clinical trial showed that adding palbociclib to an oestrogen-suppressing drug called fulvestrant as a second-line treatment for patients who had previously responded to endocrine therapy prolonged overall survival by 6.9 months. This second- or later-line combination of palbociclib with fulvestrant is funded for suitable patients in New Zealand. Palbociclib comes in pill form. Common side effects include anaemia, fatigue, nausea, diarrhoea, vomiting, mouth sores and hair thinning.

Click here to read a fact sheet on palbociclib (Ibrance).

Targeted therapies not yet funded in New Zealand

Anti-HER2 therapies

Sub-cutaneous trastuzumab is an alternative formulation of trastuzumab that can be given by injection rather than by intravenous infusion. This has huge benefits in terms of convenience and efficiency as it can be administered without a lengthy visit to an infusion centre at a hospital. Australia funds this version of this medicine but New Zealand does not. The supplier applied to PHARMAC for funding in 2013, but was told in 2015 that it would only be considered if the product could be made ‘cost-neutral’, i.e. the same as the intravenous formulation. There has been no further progress with this.

Trastuzumab biosimilars are alternative brands of trastuzumab to the original Herceptin® brand. Because trastuzumab is a ‘biologic’ medicine - a monoclonal antibody that has to be grown in a living cell culture system, rather than a drug that can be produced by a purely chemical reaction – the alternative brands are known as ‘biosimilars’ rather than ‘generics’.

Currently, Herceptin® is the only version of trastuzumab that is publicly funded by PHARMAC in New Zealand, but there are several biosimilars now on the global market. This competitive situation has led to price reductions. Four trastuzumab biosimilars have been approved by Medsafe NZ – Herzuma®, Ogivri®, Trazimera® and Kanjinti®. A fifth, Ontruzant®, has not yet been approved by Medsafe. All five trastuzumab biosimilars are publicly funded in Australia. As of 1st November 2023 Pharmac will fund the biosimilar trastuzumab Herzuma®. 

Tyrosine kinase inhibitors

Tucatinib (brand name Tukysa®) is a selective HER2 tyrosine kinase inhibitor which was approved by the United States FDA in May 2020 for treatment of HER2-positive metastatic breast cancer. Results of the HER2CLIMB clinical trial presented in May 2020 showed that tucatinib combined with the chemotherapy drug capecitabine demonstrated survival benefits in patients who had already progressed after several lines of treatment. Encouragingly, these benefits were also seen among patients who had brain metastases. Often cancer medicines do not work well for these tumours as there is a ‘blood-brain barrier’ which normally functions to protect the brain, but has the unfortunate side-effect of preventing many medicines from getting into this tissue.

Neratinib (brand name Nerlynx®) is another tyrosine kinase inhibitor. This drug is approved in the United States in combination with the chemotherapy drug capecitabine for those whose HER2-positive metastatic breast cancer has progressed on two previous lines of anti-HER2 therapy (such as trastuzumab, pertuzumab or trastuzumab emtansine). Recent research results have shown that it is also effective in treating early breast cancer that is both HER2-positive and hormone receptor-positive. In New Zealand, Nerlynx® was approved by Medsafe in June 2020. It is not funded by PHARMAC.

For more information on neratinib (Nerlynx) click here.

Antibody-drug conjugates

Trastuzumab deruxtecan (brand name Enhertu®) is an antibody-drug conjugate composed of trastuzumab, which targets the drug to HER2 receptors on breast cancer cells, and deruxtecan, a cytotoxin which then kills those cells. Clinical trials called DESTINY- Breast03 and DESTINY- Breast04 have recently shown that this medicine improves survival in two groups of patients – those whose HER2-positive metastatic breast cancer has returned after first line treatment with trastuzumab and taxanes, and also those with ‘HER2-low’ metastatic breast cancer. HER2-low is a new category – up until now these cancers have been lumped together in the HER2-negative category.

Read more about trastuzumab deruxtecan (Enhertu) here.

Sacituzumab govitecan (brand name Trodelvy®) is an antibody-drug conjugate that blocks cancer cell proliferation by interfering with DNA repair. The antibody sacituzumab targets the drug to a DNA-enzyme (topoisomerase 1) complex in the cell and the govitecan molecule binds to the DNA and causes it to break, thus halting cell replication. In April 2020, a Phase III trial called ASCENT was stopped early because sacituzumab-govitecan worked so well in patients with triple negative metastatic breast cancer, it was not necessary to continue the trial. On this evidence, sacituzumab govitecan was given accelerated approval by the FDA in the United States in April 2020. It is publicly funded in Australia (March 2022) and England (July 2022), but is not approved by Medsafe or funded by PHARMAC in New Zealand. BCAC has contacted the pharmaceutical company Gilead Sciences to encourage them to apply for Medsafe registration and PHARMAC funding for Trodelvy and to establish a cost-share programme for NZ patients until funding is secured.

CDK 4/6 inhibitors

Ribociclib and Abemaciclib. As explained above, only one CDK 4/6 inhibitor, palbociclib, is funded in New Zealand to be used with an endocrine therapy such as fulvestrant or an aromatase inhibitor in those with hormone receptor-positive metastatic breast cancer. Two other CDK 4/6 inhibitors are ribociclib (brand name Kisqali®) and abemaciclib (brand name Verzenio®). All three have been shown to improve survival and each offers slightly different benefits. All three are publicly funded in Australia and the UK.

To read more about ribociclib (Kisqali), click here.

mTOR, PI3K and AKT inhibitors

mTOR, PI3K and AKT are three enzymes that interact in a signalling pathway that is vital for regulating normal cell proliferation. However, in many cancers this pathway is overactive leading to uncontrolled cell growth. Inhibitors of AKT, mTOR and PI3K can therefore be useful in treating cancer by bringing this process under control. 

Everolimus (brand name Afinitor®) is an mTOR inhibitor. It stops a particular protein called mTOR from working properly. mTOR controls other proteins that trigger cancer cells to grow. It is used in the treatment of hormone receptor-positive, HER2-negative metastatic breast cancer in post-menopausal women, in conjunction with the aromatase inhibitor exemestane after failure of letrozole or anastrozole. It is only used in patients whose tumour has tested negative for HER2.

Everolimus is not Medsafe approved or publicly funded for breast cancer in New Zealand. It has been funded in Australia since 2014. In July 2018 BCAC applied to PHARMAC to have this medicine funded. In July 2019, BCAC was informed that this application had been declined by PHARMAC.

Read more about everolimus (Afinitor) here.

Alpelisib (brand name PIQRAY®) is an inhibitor of an enzyme called PI3K which is part of a biochemical pathway that normally controls cell proliferation in our bodies. In some cancers, the gene encoding PI3K is mutated (called a PIK3CA mutation) and PI3K is over-expressed, contributing to tumour growth. Alpelisib can inhibit PI3K and help to reduce the growth of cancer cells. Novartis, the manufacturer of alpelisib, supplies it along with a test for the PIK3CA mutation, as a product called PIQRAY.

In May 2019 the USA FDA approved PIQRAY for use with fulvestrant to treat those whose hormone receptor-positive, HER2-negative, PIK3CA-mutant metastatic breast cancer had progressed on endocrine therapy. In the SOLAR-1 phase III clinical trial, those receiving this combination had had median progression-free survival of 11.0 months, compared to only 5.7 months for those receiving fulvestrant alone. There is an Australian-based clinical trial with alpelisib (called CAPTURE) under way at present (July 2022), but it is not open to New Zealand patients. PIQRAY was funded in England in July 2022.

Current clinical trials with mTOR, PI3K and AKT inhibitors include:

CAPTURE: A Phase II Australian study using alpelisib (PI3K inhibitor) as a later-line treatment for hormone receptor-positive, HER2-negative metastatic breast cancer that has returned after treatment with a CDK 4/6 inhibitor in patients who test positive for the PIK3CA mutation in a blood test (circulating tumour (ct) DNA test).

BYLieve: Phase II American trial of alpelisib with fulvestrant or letrozole for the treatment of PIK3CA-mutant, hormone receptor-positive, HER2-negative metastatic breast cancer that has progressed on CDK 4/6 inhibitor therapy.

LOTUS: Final results from this Phase II international trial using ipatasertib (an AKT inhibitor) and paclitaxel for the treatment of triple negative metastatic breast cancer were presented in May 2020. Those receiving ipatasertib had median overall survival of 25.8 months compared to 16.9 months for those receiving only paclitaxel. 

IPATunity170: Phase III follow-up to LOTUS, investigating ipatasertib plus the immunotherapy drug atezolizumab (Tecentriq®) plus paclitaxel for triple negative metastatic breast cancer.

INAVO120: Phase III trial of a PI3K inhibitor (GDC-0077) plus palbociclib plus fulvestrant for PIK3CA-mutant, hormone receptor-positive, HER2-negative locally advanced or metastatic breast cancer.

PARP inhibitors

This group of drugs has shown promising results in trials with women who have triple negative breast cancer and/or hereditary breast cancer caused by mutations to the BRCA1 and BRCA2 genes. PARP inhibitors are also useful for some types of ovarian cancer which are associated with BRCA gene mutations. A PARP is an enzyme which repairs everyday damage done to our DNA, but it also repairs cancer cells damaged by chemotherapy drugs. PARP inhibitors stop the PARP enzyme from repairing damaged cancer cells and thus allow chemotherapy drugs to work more effectively.

Several PARP inhibitors are being tested in clinical trials, but so far only olaparib (brand name Lynparza®) and talazoparib (brand name Talzenna®) have been commercialised for use against HER2-negative metastatic breast cancer in women with BRCA mutations. Both come in pill form. In New Zealand, olaparib is funded for treatment of ovarian cancer but not breast cancer.

You can read more about olaparib (Lynparza) here.

Immunotherapy drugs (also called immune checkpoint inhibitors)

These drugs, called immune checkpoint inhibitors, are synthesised monoclonal antibodies designed to lock on to specific molecular targets in our bodies. They are designed to attach to a protein called PD-L1, which normally acts as a ‘brake’ or ‘checkpoint’ on the immune system. In cancer, this checkpoint system is not always helpful as a stronger immune response can help to control the cancer. When the checkpoint inhibitor blocks PD-L1, it unleashes the brake on the immune system, allowing it to attack the cancer cells.

Pembrolizumab (brand name Keytruda®) is an immune checkpoint inhibitor that is useful in treating several types of cancer. It is funded in New Zealand for treating advanced melanoma, and recently funding was also approved for lung cancer. Breast cancer clinical trials currently under way with pembrolizumab and other similar drugs are producing very promising results, particularly in triple negative breast cancers that test positive for the tumour masking protein, PD-L1. In the United States, the FDA has approved pembrolizumab for use in both early and metastatic triple negative breast cancer.

Atezolizumab (brand name Tecentriq®) is another checkpoint inhibitor. It has been shown in clinical trials to improve survival in patients with triple negative metastatic breast cancer whose tumours have high PD-L1 expression. Tecentriq® is not PHARMAC-funded, but the supplier Roche has applied to PHARMAC for this and at present offers a Cost Share Programme (contact nz.costshare@roche.com for more information).

14 July 2022

Chemotherapy involves the use of special drugs to attack and kill breast cancer cells. 

For women with early breast cancer, chemotherapy can prevent breast cancer from recurring by killing any remaining cancer cells that may have spread to other parts of the body at the time of surgery.

For women with advanced breast cancer, chemotherapy can destroy much of the cancer reducing tumour size and symptoms.

On these pages, you'll get more information about:

• what chemotherapy involves

• chemotherapy drugs

• chemotherapy side-effects

Having chemotherapy

Some chemotherapy drugs are given as tablets, but more commonly chemotherapy is administered as an "infusion". 

This means the drug is delivered by injection into the bloodstream through a vein, usually at three to four week intervals, known as "cycles". 

If your treatment team is concerned about finding your veins for infusions, you may have a small device called a ‘portacath’ inserted under the skin on your upper chest or arm.  The portacath is a long thin plastic tube which can be left in place over a period of months or even years and is used to inject repeated doses into your blood stream and/or to sample blood.

Chemotherapy infusions usually occur in a hospital outpatient clinic, where you visit as a day patient. 

If you have made a decision to receive chemotherapy be sure to ask about:

• the course and the drugs being used

• the length of the course

• the benefits to you

• potential side effects.

Chemotherapy drugs

Chemotherapy aims to kill the cancer cells in your body, but will temporarily affect some of your other cells as well.  There are many different chemotherapy drugs and they are often used in combination to provide the most effective treatment. 

Typically you will receive a combination of chemotherapy drugs. These drugs all interfere with the formation and copying of DNA (gene material). They work in different ways and by using them together they are more effective.  The drugs can have a number of side effects, which are almost always temporary and discussed below.

The most common types of chemotherapy drugs are:

Alkylating agents (.eg. cyclophosphamide).  These drugs attach a chemical called an alkyl group (_CnH2n+1) to DNA (which forms our genes and chromosomes), and interfere with the process of copying DNA as cells divide. Cancer cells develop with multiple gene mistakes (mutations) which make them less able to repair such DNA damage and lead to them being killed by the chemotherapy. Normal cells that are dividing also suffer temporary damage, but are rapidly repaired. This temporary damage leads to many of the side effects of chemotherapy, which are again almost always temporary.

Antimetabolites (e.g. methotrexate).  These drugs are essentially false building blocks for DNA which are taken up into dividing cells and interfere with the copying of DNA. Again normal cells are readily able to remove these drugs, but cancer cells are often killed.

Anthracyclines (e.g. adriamycin and epirubicin) These were originally isolated from bacteria as natural antibiotics, but they were found to be one of the most active types of chemotherapy ever developed. They interfere with the untangling of DNA and lead to cell death in many types of cancer, but again cause only temporary damage to normal cells. After extensive treatment with these drugs, the pumping strength of the heart can be affected, but your oncologist will check for any risk factors for this rare problem.

Taxanes (e.g. paclitaxel and docetaxel).  These are a new type of drug, originally derived from the bark or needles of yew tree species. They interfere with the separation of chromosomes as cells divide. They can cause some different side effects to other drugs e.g. nerve damage and allergic reactions, which your treatment team will try and prevent.

In recent years a number of innovative new medicines have become available for the treatment of early and advanced breast cancer. However, many of these medicines are not funded in New Zealand. Read more about some of these medicines here.

Side effects of chemotherapy

Each type of drug and combination of drugs may have different side-effects, as the chemotherapy drugs will temporarily damage normal cells as well as the cancer cells.  This damage is often quickly repaired in normal cells, but is not so easily repaired in cancer cells causing them to die.

Below is a list of possible side effects.  Remember, you will not get all of these side-effects and most can be minimised and often prevented from occurring.  Most side effects are predictable in terms of their onset, duration and severity and they are usually reversible.

Your medical oncologist will indicate which side effects are most relevant for you.  Click on the one you are most interested in to find out more about it and what can be done to limit its impact.

Common side effects:

• An increased risk of infection

• nausea and loss of appetite

• hair loss

• fatigue

• weight gain

• constipation or diarrhoea

• disruption to your menstrual cycle

• infertility

Less common side effects:

• mouth ulcers

• joint or muscle pain in arms or legs

• tingling, burning or numbness in hands and feet

• skin and nail problems

• memory loss

• allergic reactions

• heart damage

Common side effects

Immune suppression and increased risk of certain infections

Chemotherapy drugs reduce the number of white blood cells in your body for a short time, usually the 10 to 14 days after chemotherapy is given.  This means your immune system may be compromised and you may be more susceptible to infection.  You may not be able to fight an infection as well as you normally would and infections can behave more seriously.

If you suffer from a high fever, severe sweats or chills seek medical assistance immediately.  These are signs of a possible severe infection and can be dangerous.

Nausea and loss of appetite

Vomiting and feeling sick are common side effects of chemotherapy.  Anti-emetic drugs can help to ease nausea and these are given just prior to your chemotherapy and sometimes for several days afterwards.

Your doctor will usually start you on an anti-emetic regime that eases nausea for most people. New anti-nausea drugs such as Emend (aprepitant) are available for use in conjunction with those chemotherapy drugs that are more likely to cause sickness and have provided a very effective means of fighting chemotherapy-induced nausea.

One way you can help yourself to try and minimise nausea is to drink plenty of non-alcoholic liquids - more than you usually do.

Hair loss

You may lose your hair depending on the type of chemotherapy programme you undergo.  This can range from mild thinning to complete hair loss.  When the hair grows back it may be thicker and curlier or it may grow back a different colour.

Hair loss can be very distressing.  Some women chose to cut their hair before it falls out, while other use wigs, scarves and hats to cover hair loss. 

In New Zealand, the Government will subsidise the cost of a wig.  For more details go to the Ministry of Health website here for the Wigs and hairpieces subsidy. 

Fatigue

Chemotherapy often makes women feel tired.  It may take several months after treatment for you to fully recover your energy.

During treatment get as much help as you can with practical tasks.  Get lots of rest, but also remember to exercise. Exercise will actually minimise tiredness and help to prevent weight gain.

Weight gain

Many women may actually gain weight during chemotherapy.  An exercise plan and healthy diet will help to maintain your optimal weight.

Constipation or diarrhoea

Some drugs, particularly antiemectics (or anti-nausea drugs) can cause constipation, while others can cause diarrhoea. 

With both conditions make sure you are drinking plenty of water.  Medication can be taken to treat the symptoms of diarrhoea, while lifestyle changes, such as eating high-fibre foods and getting regular exercise, can help to alleviate constipation.

Disruption to your menstrual cycle

Chemotherapy will often cause your periods to stop for a time or bring about an early menopause (periods stop permanently).  This is because the medication affects the levels of oestrogen in your body which affects the follicles in the ovaries.  Some menopausal symptoms can be unpleasant (e.g. hot flushes, vaginal dryness) so discuss ways to prevent or alleviate these with your medical team.  If you're a younger woman who experiences temporary menopause, you might like to check our fertility page.

Infertility

Chemotherapy can result in permanent menopause and could impact your fertility if you are of child-bearing age.  If you are planning to have children, talk about fertility issues with your surgeon before you are referred to an oncologist for chemotherapy, as you may wish to discuss these matters with a fertility specialist.  If it is likely you will experience menopausal symptoms – or perhaps experience an early menopause – then it may be helpful to find out more about these changes and how they will affect you.  For more information on preserving fertility see our fertility page.

Less common side effects (often occuring with only one type of drug)

Mouth ulcers

Women undergoing chemotherapy occasionally experience mouth ulcers, throat sores, cold sores and/or thrush. To prevent these  problems make sure you keep your mouth clean.  Your chemotherapy nurse will advise you on the best mouthwash to use.

Joint or muscle pain in arms or legs

Certain chemotherapy medication can cause discomfort in the joints or muscles.  Tell your doctor if you are experiencing this kind of discomfort because you may be able to take a different or additional medication.

Tingling, burning or numbness in hands and feet

These symptoms can occur as the result of nerve damage associated with some chemotherapy drugs, usually taxanes.  Tell your doctor if you have persistent symptoms, as he or she may lower the dose or stop the drugs.

Skin and nail problems

Hyper-sensitive or itchy skin and brittle or cracked nails can occur, but are not usually serious.  Skin can feel sensitive to touch, may appear red and itchy and be more prone to sun damage.  Make sure you protect yourself from the sun and use appropriate moisturisers – ask your breast or chemotherapy nurse for advice. 

Nails may be more prone to infection, especially if they are cracked or brittle.  Keep nails well trimmed and wear gloves when gardening or have your hands in water.

Memory loss

Some chemotherapy treatment can result in minor short-term memory difficulties, often known as "chemo brain". If you are experiencing these symptoms talk to your medical team about what can be done.

Allergic reactions

Allergic reactions may occur when you are given Taxanes. They can be severe in up to three per cent of cases, but are almost always prevented with anti-allergy drugs given prior to treatment.

Heart Damage

In very rare cases, heart damage may occur with certain drugs, such as Adriamycin and epirubicin. The risks are very low unless women have pre-existing heart problems. Make sure you tell your oncologist about any history of heart disease.

Find out more

• You might like to read our pages on coping with the physical and emotional side-effects of breast cancer treatment.
• Check out the chemotherapy section of the New Zealand guidelines on the Management of Early Breast Cancer, which contains information on best-practice treatment options.

Radiation therapy uses radiation to destroy cancer cells in the body. In many cases it can significantly reduce the risk of cancer recurring.  

It is routinely used as a follow up treatment after a partial mastectomy (lumpectomy or wide local excision) and sometimes after a full mastectomy to help kill any cancer cells that may still be present in the surgery area.  

It can be used at different times in the treatment cycle. Many women have radiation treatment immediately after surgery, but depending on your circumstances you may have it after chemotherapy.  It is often used in conjunction with other treatment options and often combined with endocrine treatment.

External Beam Radiation Therapy

This is the most common type of radiation therapy. A course of radiation is usually given daily (except weekends) over a five or six week period, although faster courses are being trialled in some areas. Your treatment will be overseen by a radiation oncologist.

In some cases, a shorter three weekly treatment period may be used in which are given higher radiation doses. This is known as hypofractionation and is used in some cancer centres in New Zealand.  However, this radiation method is not suitable for certain types and/or stages of breast cancer. 

Treatment involves an examination of the area to be irradiated.  Your oncologist will then determine how much total radiation is needed to treat the affected area. This total dose will then be delivered as a number of daily doses. 

You will have a few small dots tattooed on your body to help guide the therapist to ensure the correct area is treated. The treatment sessions are usually short and will involve the therapist using a machine called a linear accelerator (pictured right) to aim a beam of high-energy radiation at the area affected by cancer. The angles used and special blocking techniques ensure that only the affected area is exposed to radiation.  

Radiation therapy is most effective when it is continuous and a full course is completed, so it’s important to keep your scheduled appointments. It can seem tiring making the daily trip to your radiation therapist, so try to make appointments at times of the day that are easy for you. Having a friend or family member drive you to appointments can be helpful too.

You may be able to return to work during this phase of your treatment, but remember to get lots of rest and relaxation.

Side effects of radiation therapy

Radiation therapy is often quite easy to tolerate and the side-effects are generally limited to the affected area. Side-effects from radiation therapy tend to be cumulative, that is they become more pronounced as the course continues.

You may experience:

• fatigue 

• the irradiated skin may become very sensitive, like a bad case of sunburn

• lymphoedema if your lymph nodes have been irradiated.

Skin reactions are the most common side-effect. These are often worse if you:

• have chemotherapy at the same time as radiation therapy

• are overweight

• have other health problems, such as diabetes

• have sun-damaged skin

• smoke.

You can help to protect your skin by:

• washing with a mild soap and using a light moisturiser. Your medical team can recommend appropriate products.

• using sunscreen on the affected area and wearing sun-protective clothing

• protecting the affected area from damage and irritants, eg cuts, grazes, perfume, deodorant, etc

• keeping the skin dry.

Your medical team will be able to give you more advice on skin care before, during and after radiotherapy, and will give you detailed information about other potential side-effects. 

Find out more

Read the radiation therapy section of the New Zealand Guidelines on the Management of Early Breast Cancer, which outlines best practice treatment options.