Chemo Experts, the easiest way to learn about cancer treatment
Find a Treatment:
Cancer Types
or
Treatments

Treatment Name: Dose Dense AC (DD-AC, Doxo­rubicin + Cyclo­phospha­mide) followed by TH (Taxol® + Herceptin®)

Dose Dense AC (DD-AC, Doxo­rubicin + Cyclo­phospha­mide) followed by TH (Taxol® + Herceptin®) is a Chemotherapy Regimen for Breast Cancer - early stage

How does DDAC-TH work?

  • Doxorubicin, cyclophosphamide, and paclitaxel are designed to kill or slow the growth of cancer cells
  • Trastuzumab targets a protein on the surface of breast cancer cells known as Human Epidermal growth factor Receptor-2 (HER-2) and marks it for destruction by the immune system; this is also known as immunotherapy

DD - Dose Dense (shorter amount of time than the originally studied time frame to give chemotherapy doses)

A – Adriamycin® (Doxorubicin)
C – Cyclophosphamide (Cytoxan®)

T – Taxol® (Paclitaxel)
H – Herceptin® (Trastuzumab)

Goals of therapy:
DDAC-TH is often given with the goal of cure and administered either before surgery (neoadjuvant therapy) to shrink the size of the tumor, or after surgery (adjuvant therapy) to kill any cancer cells that may be still present in the body.

Schedule

DDAC:

  • Doxorubicin intravenous (I.V.) push over 5 to 15 minutes on Day 1
  • Cyclophosphamide I.V. infusion over 30 to 60 minutes on Day 1
  • Each Cycle is 14 days; four cycles is standard treatment length

Estimated total infusion time for this treatment:

  • Up to 2 hours for Day 1 of each cycle of DDAC
  • Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and I.V. fluids, such as hydration, may add more time

 

TH (starts after completion of all DDAC cycles):

  • Paclitaxel I.V. infusion over 3 hours on Day 1
  • Trastuzumab I.V. infusion over 90 minutes on Day 1 of Cycle 1
    • then, Trastuzumab I.V. infusion over 30 minutes on Day 8 of Cycle 1
    • then, Trastuzumab I.V. infusion over 30 minutes on Days 1 and 8 of Cycles 2 through 4

                                           THEN

  • Trastuzumab I.V. infusion over 30 minutes every 21 days for up to 44 weeks

Estimated total infusion time for this treatment:

  • Up to 6 hours for Cycle 1, Day 1 of TH; as short as four hours for each remaining treatment
  • Up to one hour when trastuzumab is given alone
  • Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and I.V. fluids, such as hydration, may add more time

During TH treatment, paclitaxel is given every 14 days and trastuzumab is given every seven days for the first eight weeks. Then, trastuzumab is given alone every 21 days for 44 weeks.

DDAC-TH is usually given in an outpatient infusion center, allowing the person to go home afterwards. On occasion, it may be given in the hospital if someone is too sick. Duration of therapy may last up to 12 months, depending upon response, tolerability, and number of cycles prescribed.

Click here for the common DDAC-TH starting doses.

Side Effects

In a multi-drug regimen, each chemotherapy medication has unique side effects. When these medicines are given together, drug-related side effects reported in clinical studies give the best estimate of what to expect. In clinical studies, the most common side effects reported from DDAC-TH are shown here:

  • Fatigue, (96%)
  • High blood sugar, (89%)
  • Low red blood cells [anemia], (86%)
  • Tingling or numbness in fingers and toes, (82%)
  • Nausea, (74%)
  • Mouth sores, (49%)
  • Bone pain, (44%)
  • Diarrhea, (43%)
  • Shortness of breath, (41%)
  • Joint pain, (39%)
  • Low platelets [thrombocytopenia], (35%)
  • Constipation, (30%)
  • Low white blood cells [neutropenia], (26%)
  • Fever, (25%)
  • Headache, (24%)
  • Vomiting, (19%)
  • Muscle pain, (18%)
  • Heartburn, (17%)
  • Dizziness, (17%)
  • Changes in fingernails and toenails, (17%)
  • Neutropenic fever, (6%)
  • Muscle weakness, (3%)
  • Heart failure, (1%)

On average, 9% of patients discontinue treatment due to unacceptable side effects, most commonly due to decreases in heart function.

Side effect videos Side Effect Videos
Fatigue Fatigue AnemiaAnemiaNausea and VomitingNausea and VomitingPainPainDiarrheaDiarrheaConstipationConstipationNeutropenic FeverNeutropenic FeverHair LossHair Loss

Monitoring

How often is monitoring needed?
Labs (blood tests) may be checked before each treatment. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), plus any others your doctor may order.

How often is imaging needed?
Imaging may be checked before treatment and after treatment as directed by your doctor. Imaging may include: magnetic resonance imaging (MRI), computerized tomography (CT) scans, or positron emission tomography (PET) scans. Echocardiograms (Echo) to check heart function are typically performed prior to starting treatment, after completion of DDAC therapy, then typically every 3 to 6 months or as directed by your doctor.

How might blood test results/imaging affect treatment?
Depending upon the results, your doctor may advise to continue DDAC-TH as planned, reduce the dose of future treatments, delay the next dose until the side effect goes away, or switch to a different therapy.

ChemoExperts Tips

  • Drink plenty of fluids (1 to 2 liters per day), especially on days when cyclophosphamide is given. This will help flush the bladder and avoid bladder toxicity from a break-down product (metabolite) of cyclophosphamide called acrolein. Adequate fluid intake may also help prevent nausea or vomiting
  • Typically, filgrastim (Neupogen®) or pegfilgrastim (Neulasta®) is given after DDAC chemotherapy to stimulate production of white blood cells and avoid periods of neutropenia
  • Paclitaxel may cause a reaction during the infusion known as hypersensitivity. The reaction is most often prevented using several pre-medications, such as diphenhydramine (Benadryl®), either ranitidine or famotidine, and a steroid such as dexamethasone
  • A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately
  • Clinical trials may exist for breast cancer. Ask your doctor if any studies are currently enrolling in your area. If not, go to clinicaltrials.gov to search for other centers offering study medications

Patient Assistance & Co-payment Coverage

Patients under the age of 65 years, or those with private insurance plans:
If you have insurance and are looking for patient assistance or copay assistance for Dose Dense AC (DD-AC, Doxo­rubicin + Cyclo­phospha­mide) followed by TH (Taxol® + Herceptin®), we have provided links that may help.

Visit our Patient Assistance page and click the links to various patient assistance programs for help paying for Dose Dense AC (DD-AC, Doxo­rubicin + Cyclo­phospha­mide) followed by TH (Taxol® + Herceptin®). Depending upon your income, they may be able to help cover the cost of:

  • Doxorubicin
  • Cyclo­phospha­mide IV
  • Paclitaxel
  • Trastuzumab

For Branded medications (may be available for generic medications too), check with the manufacturer to determine if a co-pay card is offered and if it could reduce your monthly copay.

  • If you are uninsured, check with the manufacturer to determine if you are eligible to receive medication at no cost.

Medicare and Medicaid patients (Patients 65 years or older):
The clinic providing treatment will likely pre-authorize medications and immune therapies such as Dose Dense AC (DD-AC, Doxo­rubicin + Cyclo­phospha­mide) followed by TH (Taxol® + Herceptin®) and are the best source to help you understand drug cost.

  • Ask to speak with a patient assistance technician or financial counselor at the clinic or hospital administering this therapy.

Emotional Wellness

What is Emotional Wellness?
Emotional wellness is having a positive outlook balanced with a realistic understanding of current life events. This requires both an awareness and acceptance of your emotions. It is with this knowledge that you can develop a plan to take the necessary actions to positively impact your life.

Emotional wellness uses an ongoing process to continually reflect on the stressors of life in a constructive manner to move forward and create happiness.

Because emotional wellness is deeply connected with physical, social, and spiritual wellness, pursuing it often becomes particularly difficult in times of major illness. Despite this difficulty, working toward emotional wellness has been connected to improved treatment outcomes and a higher likelihood of achieving goals of therapy.

Learn more about pursuing emotional wellness while receiving treatment with Dose Dense AC (DD-AC, Doxo­rubicin + Cyclo­phospha­mide) followed by TH (Taxol® + Herceptin®)

Individual Drug Label Information

Doxorubicin (Adriamycin®)

  • Doxorubicin is administered as an intravenous infusion and is red in color
  • Can affect heart function. A heart study (echocardiogram) may be required before receiving the first dose
  • Dosage may be reduced in patients with poor liver function
  • Has been linked to the development of other cancers in a small number of people (1.5% chance at 10 years)
General Doxorubicin (Adriamycin) Side Effects
  • Nausea, vomiting, diarrhea, and mouth sores (stomatitis)
  • Leakage into skin or surrounding muscle during infusion may cause severe irritation (extravasation)
  • May temporarily turn urine orange
  • Hair loss, which is usually reversible
  • Increased risk of infection due to decrease white blood cell count (neutropenia)
  • Click on the doxorubicin (Adriamycin) package insert for reported side effects and possible drug interactions

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaHair LossHair LossPainPainNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

Cyclo­phospha­mide IV (Cytoxan®)

  • Cyclophosphamide is administered as an intravenous (I.V.) infusion
  • May decrease the ability to become pregnant. Fertility preservation is recommended in couples wishing to become pregnant.
  • A smaller dosage may be required for patients receiving hemodialysis
  • Has been linked to the development of other cancers in a small number of people
General Cyclophosphamide (Cytoxan) Side Effects
  • Low white blood cell count which can increase the risk of infection
  • Nausea or vomiting, which can be acute (first 24 hours) or delayed (Days 2 – 5)
  • Hair loss, which is usually reversible
  • Click on the cyclophosphamide (Cytoxan) package insert below for reported side effects and potential drug Interactions

Side Effect Videos
Nausea and VomitingNausea and VomitingHair LossHair LossNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

Paclitaxel (Taxol®)

  • Paclitaxel is an intravenous infusion
  • There is a risk for serious infusion reactions such as trouble breathing, low blood pressure, severe swelling, or hives. These reactions are due to a component in the solution called Cremophor. You will receive several medications before receiving paclitaxel to decrease the risk of experiencing an infusion related reaction that include: a corticosteroid, diphenhydramine (Benadryl), and histamine-2 antagonists (Zantac or Pepcid).Patients who experience these type of severe reactions should not be rechallenged with paclitaxel.
  • This drug can cause low white blood cell counts. Complete blood counts (CBC) will be checked before each treatment to make sure your white blood cells are at a safe enough to use this drug
  • Dosage adjustments may be required for liver dysfunction, nerve pain or toxicity, low white blood cells, or low blood platelets
  • Nerve pain usually starts as tingling or a "pins and needles" feeling in the fingers or toes, but can worsen over time and lead to numbness. It is important to notify the doctor if there are any signs of nerve damage. If caught early, this is typically reversible but can become permanent if not addressed
  • Interacts with certain antifungal, blood pressure, cholesterol, erectile dysfunction, sedative, antibiotic, and anti-seizure medications.  Ask your doctor or pharmacist to review your medications for any possible interactions
  • Known interaction with grapefruit or grapefruit juice. Avoid eating grapefruit and drinking grapefruit juice as they may increase your risk of experiencing side effects
  • Avoid the natural supplement St. John’s Wort as this can possibly decrease the effectiveness of paclitaxel
  • Injection site skin reactions can occur:  itching, skin infection, skin falling off, skin death, and redness. Report any of these to your physician, even if this occurs several days after an infusion
  • Can cause fetal harm; this drug should not be used during pregnancy.  Women should avoid becoming pregnant while on this drug
General Paclitaxel (Taxol) Side Effects
  • Low blood neutrophil count (neutropenia)
  • Low white blood cells
  • Nerve pain and general pain
  • Low red blood cells and related fatigue
  • Infusion reactions - hypersensitivity
  • Hair loss
  • Nausea
  • Diarrhea
  • Mouth sores
  • Low blood pressure
  • Liver problems
  • Constipation
  • Fever and infection
  • Bleeding
  • Injection site reactions
  • Nail discoloration; usually reversible once paclitaxel is stopped
  • Click on the paclitaxel (Taxol) package insert below for all manufacturer reported side effects and possible drug interactions

Side Effect Videos
DiarrheaDiarrheaHair LossHair LossFatigue Fatigue BleedingBleedingConstipationConstipationPainPainAnemiaAnemiaNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

Trastuzumab (Herceptin®)

  • Trastuzumab is an intravenous infusion 
  • Your heart function should be checked before starting trastuzumab and every 3 months while on therapy. If your heart's ability to pump decreases, treatment may need to be interrupted for a period of time to let your heart function to improve. You may also be started on several medications to help improve your heart function 
  • Although rare, severe lung toxicity. The risk of this side effect is increased in patients with various lung diseases who receive trastuzumab 
  • May cause severe birth defects when given to pregnant women. Use proper birth control methods while on trastuzumab and notify your doctor if you become pregnant during therapy 
General Trastuzumab (Herceptin) Side Effects 
  • Can cause infusion reactions that most likely occur during the first infusion. If these occur, you may need to receive acetaminophen, diphenhydramine, and a corticosteroid before all future doses 
  • May cause skin rash 
  • May cause persistent cough, runny nose, or trouble breathing 
  • Click on the trastuzumab (Herceptin) package insert below for reported side effects and possible drug interactions

Side Effect Videos
Fatigue Fatigue

See DailyMed package insert.

Share this page:

References

Dang C, Fornier M, Sugarman S, et al. The safety of dose-dense doxorubicin and cyclophosphamide followed by paclitaxel with trastuzumab in HER-2/neu overexpressed/amplified breast cancer. J Clin Oncol 2008;26(8):1216-22.

Direct link to: J Clin Oncol 2008;26(8):1216-22, with Appendix Tables A2 and A3 for side effects.

Created: May 1, 2018 Updated: May 1, 2018

What is Breast Cancer - early stage?

What is Early Stage Breast Cancer?
A disease of either the milk-producing glands known as lobules, or milk ducts, or other cells found in the breast. Early stage breast cancer may also affect the lymph nodes, but has not usually spread to other areas of the body. Breast cancer is the most common type of cancer diagnosed in women, but may rarely affect men as well. Breast cancer cells may have increased expression of estrogen receptors (ER positive or negative), progestin receptors (PR positive or negative), and/or HER-2 receptors (HER-2 positive or negative). The presence or lack of these receptors will help determine the most effective chemotherapy medications to give.

Genetic causes, such as the BRCA (pronounced "Bracka") mutation, significantly increase the risk of developing breast cancer. Other risk factors for breast cancer include family history of breast cancer, high fat diet, and obesity. The stage of breast cancer can vary at diagnosis and throughout treatment. Stages of breast cancer include I, II, III, and IV. The effectiveness of the treatment may depend upon the stage at diagnosis.

Types of breast cancer:
1. Hormone-receptor positive or negative (60 - 65% of patients)

  • Estrogen Receptor positive (ER)+ or negative (ER)-
  • Progestin Receptor positive (PR)+ or negative (PR)-

2. Hormone Epidermal growth factor Receptor-2 (HER-2) positive or negative (20 - 25% of patients)

  • HER-2 + (positive)
  • HER-2 -  (negative)

3. Triple Negative (15 - 18% of patients)

  • ER- and PR- and (HER-2)-
NOTE: Treatment Options listed below are not all-inclusive. Other treatments may be available. ChemoExperts provides drug information and does not recommend any one treatment over another. Only your Doctor can choose which therapy is appropriate for you.

Common Starting Doses

DDAC:

  • Doxorubicin 60 mg/m2 intravenous (I.V.) push over 5 to 15 minutes on Day 1
  • Cyclophosphamide 600 mg/m2 I.V. infusion over 30 to 60 minutes on Day 1
  • Cycle is 14 days

TH:

  • Paclitaxel 175 mg/m2 I.V. infusion over 3 hours on Day 1
  • Trastuzumab 4 mg/kg I.V. infusion over 90 minutes on Day 1 of Cycle 1
    • then, Trastuzumab 2 mg/kg I.V. infusion over 30 minutes on Day 8 of Cycle 1
    • then, Trastuzumab 2 mg/kg I.V. infusion over 30 minutes on Days 1 and 8 of Cycles 2 through 

                                        THEN

  • Trastuzumab 6 mg/kg I.V. infusion over 30 minutes every 21 days for up to 44 weeks in duration

Notes: 

  • During TH treatment, paclitaxel is given every 14 days and trastuzumab is given every 7 days for the first eight weeks. Then, trastuzumab is given alone every 21 days for 44 weeks
  • Individual doses may vary based upon your Doctor's recommendation, or drug availability.

What does Cure mean?

The word “cure” means there are no cancer cells left in the body and cancer will never come back. Depending on the cancer type and stage, this may be the true goal of therapy. However, it is very difficult to prove all cancer cells are gone. Even though images, like X-rays and MRI’s, and blood tests may not show any signs of cancer, there can be a small amount of cancer cells still left in the body. Because of this, the word “remission” is used more often. This means there are no signs or symptoms of cancer. Patients in remission are followed closely for any signs of cancer returning. Sometimes, more chemotherapy may be given while in remission to prevent the cancer from coming back.

Doctors usually do not consider a patient “cured” until the chance of cancer returning is extremely low. If cancer does return, it usually happens within 5 years of having a remission. Because of this, doctors do not consider a patient cured unless the cancer has not come back within 5 years of remission. The five-year cutoff does not apply to all cancers.

What is a CBC?

A Complete Blood Count (CBC) is a frequently ordered blood test that tells clinicians the status of your: 1) White blood cell count, 2) Hemoglobin, and 3) Platelet count at the time the test was taken.

Common uses:
1) White blood cell count (WBC): is used to determine infection risk, or response to chemotherapy. Certain chemotherapy agents may harm our good infection-fighting cells. Sometimes chemotherapy may need to be delayed to allow these cells to recover.

2) Hemoglobin: is used to determine if someone is anemic. Anytime the hemoglobin is below 12 g/dL, the person is said to be anemic. Red blood cell transfusions, and sometimes iron can be given to restore the hemoglobin level, but anemia treatment should always aim at treating the underlying cause or condition.

3) Platelet count: is used to determine if the risk of bleeding is increased or if a platelet transfusion is required to prevent bleeding. Certain medications that increase bleeding risk, such as: aspirin, certain chemotherapy agents, and blood thinners, may need to be stopped temporarily until the platelet count is within a safe range.

What is a CMP?

A Comprehensive Metabolic Panel (CMP) is a frequently ordered blood test that tells clinicians the status of your: 1) Electrolytes & Acid/Base status2) Kidney function, 3) Liver function, 4) Blood sugar, and 5) Calcium at the time the test was taken. It is commonly used to monitor liver and kidney function when beginning new medications such as chemotherapy. A total of 14 tests are run simultaneously and are shown below.

Electrolytes & Acid/Base status:
1) Sodium, 2) Potassium, 3) Carbon dioxide, 4) Chloride

Kidney Function:
5) BUN (blood urea nitrogen), 6) Serum creatinine (Scr)

Liver Function:
7) AST, 8) ALT, 9) Total bilirubin, 10) Alk Phos, 11) Albumin, 12) Total protein

Blood sugar:
13) Serum glucose

Calcium:
14) Serum calcium

What is neutropenia?

This occurs when there is an abnormally low amount of a certain type of white blood cells, called neutrophils, in the blood. These neutrophils help the body fight infections caused by bacteria and viruses.

Many chemotherapy drugs temporarily damage bone marrow where white blood cells are created, resulting in neutropenia. Please watch our video on neutropenic fever to learn more.