This information is about a chemotherapy treatment for breast cancer called MMM.
The drugs that are used
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MMM is named after the initials of the chemotherapy drugs used, which are:
How treatment is given
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MMM treatment can usually be given to you as a day patient. Before you start treatment, you'll need to have a blood test on the same day or a few days beforehand. You'll also be seen by a doctor, specialist nurse or pharmacist. If the results of your blood test are normal, the pharmacy will prepare your chemotherapy drugs. All of this may take a couple of hours.
The nurse will then put a thin, flexible tube (cannula) into a vein in your hand or arm. You may find this uncomfortable or a little painful, but it shouldn't take long. Some people have their chemotherapy given through a thin, plastic tube that is inserted under the skin and into a vein near their collarbone (central line) or passed through a vein in the crook of their arm (PICC line). Your doctor or nurse will explain more about this to you.
Before the chemotherapy, you'll be given some anti-sickness (anti-emetic) drugs. These are usually given by injection through the cannula, central line or PICC line, which is connected to a drip (infusion). Some anti-sickness medicines may be given as tablets.
The chemotherapy drugs are then given separately:
Mitomycin (a purple fluid) is given as an injection along with a drip of saline (salt water) into your cannula.
Methotrexate (a yellow fluid) is given in the same way.
Mitoxantrone (a dark blue fluid) is usually given as an infusion, but may sometimes be given as an injection, along with a drip of saline into your cannula.
Altogether, your treatment will usually take up to an hour.
Although the mitomycin is often given first, the order in which the drugs are given won't alter their effectiveness.
If you're having your treatment as a day patient you can then go home, and the cannula will be removed before you go. If you have a central or PICC line it will usually stay in place, ready for your next cycle of chemotherapy. You'll be shown how to look after the line.
You'll be given a supply of anti-sickness drugs to take home with you. It's important to take these regularly as directed, even if you aren't feeling sick. This is because some anti-sickness drugs are much better at preventing sickness than stopping it once it has started.
How often treatment is given
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Your doctor may use the word 'regimen' (eg the MMM regimen) when talking about your chemotherapy. This refers to the whole plan or schedule of the particular treatment that you are receiving.
On the first day of your treatment, you'll be given all three drugs (mitomycin, methotrexate and mitoxantrone) as described. You'll then have a three-week rest period with no chemotherapy before the next part of your treatment.
In the next part, you're given only two of the drugs: methotrexate and mitoxantrone. After this, you'll have another three-week rest period with no chemotherapy. This completes the first cycle of your treatment, which takes six weeks (42 days).
After this, you'll start the next cycle of your treatment. Usually 3-4 cycles are given over a period of 4-6 months. This makes up a course of treatment.
Each person’s reaction to chemotherapy is different. Some people have very few side effects while others may experience more. The side effects described here won't affect everyone who has MMM chemotherapy.
We have outlined the most common side effects but haven't included those that are rare and therefore unlikely to affect you. If you notice any effects that aren't listed here, discuss them with your doctor, chemotherapy nurse or pharmacist.
Risk of infection
MMM can reduce the number of white blood cells, which help fight infection. White blood cells are produced by the bone marrow. If the number of your white blood cells is low you'll be more prone to infections. A low white blood cell count is called neutropenia.
Neutropenia can begin seven days after treatment has been given, and your resistance to infection usually reaches its lowest point about 28 days after chemotherapy. The number of your white blood cells will then increase steadily and usually return to normal before your next cycle of chemotherapy is due.
Contact your doctor or the hospital straight away if:
your temperature goes above 38°C (100.4°F)
you suddenly feel unwell even with a normal temperature.
You'll have a blood test before having more chemotherapy to check the number of white blood cells in your blood. Occasionally, it may be necessary to delay your treatment if the number of your blood cells (blood count) is still low.
Bruising or bleeding
MMM can reduce the production of platelets, which help the blood to clot. Tell your doctor if you have any unexplained bruising or bleeding, such as nosebleeds, bleeding gums, blood spots or rashes on the skin. If you have black or tarry stools let your doctor know straight away. You may need to have a platelet transfusion if your platelet count is low.
MMM can reduce the number of red blood cells, which carry oxygen around the body. A low red blood cell count is called anaemia. This may make you feel tired and breathless. Tell your doctor or nurse if you have these symptoms. You may need to have a blood transfusion if the number of red blood cells becomes too low.
Feeling sick (nausea) or being sick (vomiting)
Your doctor can prescribe very effective anti-sickness (anti-emetic) drugs to prevent, or greatly reduce, nausea or vomiting. If the sickness isn't controlled, or if it continues, tell your doctor; they can prescribe other anti-sickness drugs that may be more effective.
Some anti-sickness drugs can cause constipation. Let your doctor or nurse know if this is a problem.
Feeling tired is a common side effect of chemotherapy, especially towards the end of treatment and for some weeks after it’s over. It’s important to try to pace yourself and get as much rest as you need. Try to balance this with some gentle exercise, such as short walks, which will help. If tiredness is making you feel sleepy, don’t drive or operate machinery.
MMM may cause an inflammation of the lining of the eyelids (conjunctiva) that makes your eyes feel sore, red and itchy. Let your doctor know so they can prescribe soothing eye drops if necessary.
Your mouth may become sore or dry, or you may notice small ulcers during this treatment. Drinking plenty of fluids, and cleaning your teeth regularly and gently with a soft toothbrush, can help reduce the risk of this happening. Some people find sucking on ice soothing. Tell your nurse or doctor if you have any of these problems, as they can prescribe mouthwashes and medicine to prevent or clear mouth infections.
You may notice that food tastes different. Normal taste usually comes back after treatment finishes. A dietitian or specialist nurse at your hospital can give you advice about ways of coping with this side effect.
MMM can cause diarrhoea. This can usually be easily controlled with medicine, but tell your doctor if it's severe or continues. It's important to drink plenty of fluids if you have diarrhoea.
Your urine may become a blue-green colour. This may last for up to 24 hours after you’ve had your treatment. It's normal and is due to the colour of the mitoxantrone.
Less common side effects
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This is rare, but your hair may thin or occasionally fall out completely. If this happens, it usually begins about 3-4 weeks after starting treatment, although it may occur earlier. This is temporary and your hair will start to grow back once the treatment has finished. Your hair may grow back straighter, curlier, finer or a slightly different colour than it was before. You might find it helpful to see our section on coping with hair loss.
You may develop an itchy rash. Your doctor can prescribe medicine to help with this. Rarely, your skin may darken. If it does, it usually goes back to normal a few months after treatment has finished. Your skin may temporarily have a blue tinge because of the mitoxantrone. Your tears and the whites of your eyes may also be slightly blue in colour.
During treatment with MMM and for several months afterwards, you'll be more sensitive to the sun and your skin may burn more easily than normal. You can still go out in the sun but should wear a suncream with a high sun protection factor (SPF) and cover up with clothing and a hat.
Your kidneys may be affected
This doesn't usually cause any symptoms and the effect is generally mild. Your kidneys will be checked by a blood test before each treatment.
The colour of your nails may change. They may become darker and white lines may appear on them. These usually grow out over several months once the treatment has finished.
Changes to the lungs
Mitomycin may cause some changes to the lungs. Tell your doctor if you notice any coughing or breathlessness, or if existing symptoms get worse.
Treatment with MMM may cause changes in the way your liver works, although it will return to normal when the treatment finishes. You're very unlikely to notice any problems, but your doctor will take regular blood samples to check your liver is working properly.
Changes in the way your heart works
This is a rare side effect of mitoxantrone. Tests to see how well your heart is working may be carried out before you start treatment. Tell your doctor if you experience shortness of breath, fatigue or leg swelling.
It’s important to let your doctor know straight away if you feel unwell or have any severe side effects, even if they’re not mentioned above.
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Risk of developing a blood clot
Cancer can increase the risk of developing a blood clot (thrombosis), and chemotherapy may increase this risk further. A blood clot may cause symptoms such
as pain, redness and swelling in a leg, or breathlessness and chest pain.
Blood clots can be very serious, so it’s important to tell your doctor straight away if you notice any of these symptoms. Most clots can be treated with drugs that thin the blood. The doctor or nurse can give you more information.
Folinic acid tablets
If you have bad side effects from the methotrexate, such as a very sore mouth and gritty eyes, your doctor may give you folinic acid tablets to take 24 hours after having the methotrexate.
Some medicines, including those you can buy in a shop or chemist, can be harmful to take when you're having chemotherapy. Tell your doctor about any medicines you're taking, including over-the-counter drugs, complementary therapies and herbal drugs.
Leakage into the tissue around the vein (extravasation)
If this happens when mitomycin is being given, the tissue in that area can become damaged. Tell the doctor or nurse immediately if you notice any stinging or burning around the vein while the drug is being given. This is unlikely to happen if the chemotherapy is given through a central or PICC line. If the area around the injection site becomes red or swollen at any time, you should tell the doctor or nurse on the ward. If you're at home, ring the clinic or ward and ask to speak to the doctor or nurse.
Methotrexate may interact with alcohol. It's advisable not to drink alcohol while you're having treatment.
Your ability to become pregnant or father a child may be affected by having this treatment. It's important to discuss fertility with your doctor before starting treatment.
It's not advisable to become pregnant or father a child while having MMM, as it may harm the developing baby. It’s important to use effective contraception while taking this drug, and for at least a few months afterwards. You can discuss this with your doctor.
It’s not known whether chemotherapy drugs can be present in semen or vaginal fluids. To protect your partner, it’s safest to either avoid sex or use a barrier form of contraception for about 48 hours after chemotherapy.
Loss of periods in women
Because of the effect of chemotherapy on the ovaries, women may find that their periods become irregular and may eventually stop. In some women this may be temporary, but for others it will be permanent. This will result in menopausal symptoms, such as hot flushes, sweats and vaginal dryness.
There's a potential risk that chemotherapy drugs may be present in breast milk. Women are advised not to breastfeed during chemotherapy and for a few months afterwards.
If you’re admitted to hospital for a reason not related to the cancer, it’s important to tell the doctors and nurses looking after you that you're having chemotherapy treatment. You should tell them the name of your cancer specialist so that they can ask for advice.
This section is based on our MMM chemotherapy fact sheet, which has been compiled using information from a number of reliable sources including:
Sweetman, et al. Martindale: The Complete Drug Reference. 37th edition. 2011. Pharmaceutical Press.
British National Formulary. 62nd edition. 2011. British Medical Association and Royal Pharmaceutical Society of Great Britain.
electronic Medicines Compendium (eMC). (accessed October 2011).