Atezolizumab and nab-paclitaxel

Atezolizumab and nab-paclitaxel are a combination of cancer drugs. You pronounce these drug names as:

• a-teh-zoh-liz-you-mab

• nab-pac-lih-tax-ul

They are a treatment for some people with triple negative breast cancer  who can't have surgery (unresectable) and they have either:

• locally advanced breast cancer
• secondary breast cancer . This is also called metastatic breast cancer, advanced breast cancer, or stage 4 breast cancer

How does atezolizumab and nab-paclitaxel work?

Atezolizumab is a type of immunotherapy drug called a checkpoint inhibitor. It works by blocking a protein called PD-L1 that stops the immune system from working properly and attacking cancer cells. It helps to make your immune system find and kill cancer cells. 

Before you have atezolizumab you have tests on your cancer cells to check your cancer has enough of the PD-L1 protein.

Nab-paclitaxel is a chemotherapy drug. It combines the chemotherapy drug paclitaxel with a protein called albumin. It works by stopping cancer cells separating into two new cells, so it blocks the growth of the cancer.

How do you have atezolizumab and nab-paclitaxel?

You have atezolizumab and nab-paclitaxel as a drip into your bloodstream (intravenously).

The first time you have atezolizumab, you have it over an hour. If you don’t have a reaction to it you have your next drips (infusions) over 30 minutes.

Some people stop nab-paclitaxel due to side effects so they may continue atezolizumab on its own. If this happens you may have it as an injection under your skin.

Into your bloodstream

You might have treatment through a long plastic tube that goes into a large vein in your chest. The tube stays in place throughout the course of treatment. This can be a:

• central line
• PICC line
• portacath

If you don't have a central line

You might have treatment through a thin short tube (a cannula) that goes into a vein in your arm. You have a new cannula each time you have treatment.

Risk of tissue damage

When you are having this treatment through a cannula it could damage the tissue if they leak out of the vein. This is called extravasation. This can happen anywhere along the vein that the drug is going into. It doesn’t happen very often. Tell your nurse straight away if you notice any changes such as swelling, redness, pain, burning, or a stinging feeling.

Your nurse will stop the drug treatment. And they will treat the area to relieve symptoms and reduce tissue damage. Contact your healthcare team if you develop any of these symptoms when you are at home.

Injection under your skin (subcutaneous injection)

You usually have an injection under the skin (subcutaneous injection) into the thigh.

You might have stinging or a dull ache for a short time after this type of injection but it doesn’t usually hurt much. The skin in the area may go red and itchy for a while.

How often do you have atezolizumab and nab-paclitaxel?

You have atezolizumab and nab-paclitaxel as cycles of treatment. This means that you have the drugs and then a rest to allow your body to recover.

Each cycle of treatment lasts 28 days (4 weeks). You continue treatment for as long as the treatment is working and you are not experiencing too many side effects.

If your doctor stops nab-paclitaxel due to side effects you may still continue with atezolizumab on its own. You may have this once every 3 or 4 weeks. This depends on if you have it as an injection or infusion.

There are slight differences between hospitals in how you might have this combination of cancer drugs. This is one way of having atezolizumab and nab-paclitaxel:

Cycle 1

Cycle 2 onwards

You then start the next treatment cycle.

If you have atezolizumab on its own you may have it in the following way::

You then start the next treatment cycle.

Tests

You have blood tests before and during your treatment. They check your levels of blood cells and other substances in the blood. They also check how well your liver and kidneys are working.

What are the side effects of atezolizumab and nab-paclitaxel?

Side effects can vary from person to person. They also depend on what other treatment you are having. 

When to contact your team

Your doctor, pharmacist or nurse will go through the possible side effects. They will monitor you closely during treatment and check how you are at your appointments. Contact your advice line as soon as possible if:

• you have severe side effects

• your side effects aren’t getting any better

• your side effects are getting worse

Early treatment can help manage side effects better. 

We haven't listed all the side effects here. Remember it is very unlikely that you will have all of these side effects, but you might have some of them at the same time.

Common side effects

These side effects happen in more than 10 in 100 people (more than 10%). You might have one or more of them. They include:

Increased risk of getting an infection

Increased risk of getting an infection is due to a drop in white blood cells. Symptoms include a change in temperature, aching muscles, headaches, feeling cold and shivery and generally unwell. You might have other symptoms depending on where the infection is.

Infections can sometimes be life threatening. You should contact your advice line urgently if you think you have an infection. 

Breathlessness and a cough

You might be breathless and look pale due to a drop in red blood cells. This is called anaemia.

You might also feel breathless or have a cough due to a lung infection. Less commonly these symptoms are due to lung tissue changes, making it less flexible or inflammation of the lungs.

Bruising, bleeding gums or nosebleeds

This is due to a drop in the number of platelets in your blood. These blood cells help the blood to clot when we cut ourselves. You may have nosebleeds or bleeding gums after brushing your teeth. Or you may have lots of tiny red spots or bruises on your arms or legs (known as petechiae).

High temperature

You might get a high temperature. Or you might feel cold or start shivering (chills). 

Hair loss

You could lose all your hair. This includes your eyelashes, eyebrows, underarms, legs and sometimes pubic hair. Your hair will usually grow back once treatment has finished but it is likely to be softer. It may grow back a different colour or be curlier than before. Some people may have permanent hair loss although this is rare.

Skin problems

Common skin problems include a skin rash and itching. Other skin problems include reddening, dry skin or areas of skin might darken, but these happen less often.

Rarely you might develop a severe skin reaction with this treatment. It may start as tender red patches which leads to peeling or blistering of the skin. You might also feel feverish and your eyes may be more sensitive to light. This is serious and could be life threatening.

Other rare side effects include developing flaky patches of skin which form scales (psoriasis). You might get white areas on the skin (vitiligo) and it might be sensitive to the sunlight.

To help protect your skin wear protective clothing, spend time in the shade and apply sunscreen.

Your skin usually improves when your treatment finishes.

Your healthcare team can tell you what products you can use on your skin to help.

Nerve changes

Numbness or tingling in fingers or toes can be temporary or persistent. It can improve after you finish treatment. 

Rarely some people get nerve pain. It is also called neuropathic pain. It can feel like a burning, shooting or tingling pain, or a feeling of crawling under their skin.

You may also have difficulty walking or changes to the way you walk. This can be caused by uncontrolled body movements or weak muscles.

Tell your healthcare team if you're finding it difficult to walk, feel, complete fiddly tasks such as doing up buttons or if you have nerve pain. 

Pain in different parts of your body

You might get aching or painful joints, muscles and bones. You might have pain in other areas of the body and rarely at the site where the cancer may have spread to. Tell your doctor or nurse if you have any pain. They can give painkillers to help.

Feeling or being sick

Feeling or being sick is usually well controlled with anti sickness medicines. It might help to avoid fatty or fried foods, eat small meals and snacks and take regular sips of water. Relaxation techniques might also help.

It is important to take anti sickness medicines as prescribed even if you don’t feel sick. It is easier to prevent sickness rather than treat it once it has started.

Diarrhoea

Contact your advice line if you have diarrhoea. For example, in one day you have 2 or more loose bowel movements than usual. If you have a stoma , you might have more output than normal. Your doctor may give you anti diarrhoea medicine to take home with you after treatment.

Try to eat small meals and snacks regularly. It’s best to try to have a healthy balanced diet if you can. You don’t necessarily need to stop eating foods that contain fibre. But if your diet is normally very high in fibre, it might help to cut back on high fibre foods such as beans, nuts, seeds, dried fruit, bran and raw vegetables. 

Drink plenty to try and replace the fluid lost. Aim for 8 to 10 glasses per day.

Constipation

Constipation is easier to sort out if you treat it early. Drink plenty and eat as much fresh fruit and vegetables as you can. Try to take gentle exercise, such as walking. Tell your healthcare team if you think you are constipated. They can give you a laxative if needed.

Sore mouth

Mouth sores and ulcers can be painful. It helps to keep your mouth and teeth clean, drink plenty of fluids and avoid acidic foods such as lemons. Chewing gum can help to keep the mouth moist.

Rarely you might have the feeling as though your mouth is burning.

Tell your doctor or nurse if you have a sore mouth or develop ulcers.

Loss of appetite

You might lose your appetite for various reasons while having cancer treatment. Sickness, taste changes or tiredness can put you off food and drinks.

Tiredness and weakness (fatigue)

Tiredness and weakness (fatigue) can happen during and after treatment. Doing gentle exercises each day can keep your energy up. Don't push yourself, rest when you start to feel tired and ask others for help.

Headaches

Tell your healthcare team if you keep getting headaches. They can give you painkillers to help.

Changes to the level of your thyroid hormones

The level of your thyroid hormones may drop (hypothyroidism). You may feel tired or cold, gain weight, feel sad or depressed, or your voice may deepen.

Occasionally your thyroid levels can go up. This can make you feel hot, anxious, hyperactive and you may lose weight.

You will have regular blood tests to check your thyroid hormone levels. You may need medicine to manage these levels.

Blood pressure changes

During treatment, your blood pressure may be lower or higher than usual. Your nurse will check this regularly. Your blood pressure usually goes back to normal either during treatment or when your treatment ends. 

Swelling in different parts of the body

Swelling of hands and feet is due to fluid build up. This is called peripheral oedema.

Let your doctor or nurse know if you have any swelling.

Flu-like symptoms

Symptoms include a high temperature, sore throat, runny nose, headaches, muscle aches, shivering (chills), sneezing or coughing. Less commonly you might have a stuffy nose.

Let your doctor or nurse know if you have any of these symptoms or feel generally unwell.

High blood sugar levels

This treatment can cause high blood sugar levels. You have regular tests to check your blood sugar level. You may need to check your levels more often if you have diabetes .

Rarely this treatment can increase your risk of developing diabetes.  

Occasional side effects

These side effects happen in between 1 and 10 out of every 100 people (between 1 and 10%). You might have one or more of them. They include:

• an allergic reaction to the infusion that can cause a rash, shortness of breath, redness or swelling of the face and dizziness - some reactions can be life threatening tell your nurse or doctor straightaway if you feel unwell
• sepsis - a serious reaction to an infection - signs can include feeling very unwell, not passing urine, being sick, a very high or very low temperature or shivering - contact your advice line straight away if you have any of these symptoms
• inflammation of the bowel (colitis) – this can cause diarrhoea with or without blood or pus, tummy pain or cramps, tiredness and problems having a poo
• liver changes such as liver inflammation (hepatitis) - symptoms may include yellowing of the skin or eyes, feeling or being sick, bleeding or bruising, dark urine, and stomach pain. You have regular blood tests to check how well your liver is working
• a lack of fluid in the body (dehydration) - you may feel thirsty or not be passing much wee
• difficulty falling asleep or staying asleep (insomnia)
• feeling low (depression)
• taste changes
• dizziness
• problems with balance, coordination and speech
• feeling very drowsy and finding it difficult to stay awake – do not drive or operate heavy machinery and if it becomes severe tell your doctor
• eye problems - symptoms include blurred vision, dry, watery, itchy, red and sore eyes
• the feeling of the room spinning or moving around you (vertigo)
• heart problems such as changes to your heart rate and rhythm. Rarely your heart might stop beating (cardiac arrest) or is unable to pump blood around the body properly (heart failure)
• feeling warm and reddening of the skin (flushing) - these symptoms can come and go
• indigestion - symptoms include heartburn, bloating and burping
• nail problems - they may become thicker, painful, discoloured or separate from the nail bed
• feeling anxious
• low level of minerals in the blood, such as potassium, sodium, and magnesium. Rarely your phosphate and calcium levels might drop
• a numb mouth
• generally feeling unwell
• weight changes - you often lose weight. Rarely you might put weight on with this treatment
• fainting 
• changes to your voice making you sound hoarse
• kidney problems such as inflammation (nephritis) – symptoms include foamy, bubbly or dark urine, swelling of the legs, ankles or feet, passing urine less often or your weight goes up. You have blood or urine tests to check for changes
• a build up of lymph fluid that causes swelling in a part of the body (lymphoedema)

Rare side effects

These side effects happen in fewer than 1 in 100 people (less than 1%). You might have one or more of them. They include:

• blood clots that can be life threatening - signs are pain, redness and swelling where the clot is. Feeling breathless can be a sign of a blood clot in the lung. Contact your advice line or doctor straight away if you have any of these symptoms
• inflammation of the heart muscle (myocarditis) - symptoms include breathlessness, feeling tired, chest pain, swelling of the ankles or legs, irregular heartbeat and fainting
• inflammation of the muscles (myositis) - causing pain, weakness, tiredness
• inflammation of the pancreas - symptoms include severe tummy pain, feeling or being sick, a high temperature or you may have loose poo
• the immune system attacking the nervous system (Guillain-Barre syndrome) - causing numbness, weakness and pain in the body. Go to A&E if you have any numbness or are unable to move
• your adrenal glands not making enough important hormones (cortisol and aldosterone)
• inflammation of the membranes covering the brain and spinal cord (meninges) - causing symptoms similar to meningitis (stiff neck, unable to look at bright light and headache)
• inflammation of the covering of the nerves in the spinal cord (myelitis) - symptoms include muscle weakness making it difficult to move about and do things. You may have problems controlling your bladder or bowel
• inflammation of the pituitary gland
• a rare condition where the immune system makes too many white blood cells which can cause severe inflammation and damage to tissues such as the liver, spleen and bone marrow 
• feeling very thirsty
• restlessness
• being shaky
• ear problems such as ringing in the ears (tinnitus) or ear pain
• feeling cold in your hands and feet
• bleeding from the back passage (rectum)
• difficulty swallowing and talking
• passing wind
• sweating more than usual
• problems going for a wee - you may have pain, blood when you wee, go more often than usual including at night, or be unable to hold it in

Other side effects

There isn't enough information to work out how often these side effects might happen. You might have one or more of them. They include:

• changes to the levels of chemicals in your blood due to the breakdown of tumour cells (tumour lysis syndrome) - you have regular blood tests to check for this

• damage to one or more of the nerves that control eye movement and the face muscles

Coping with side effects

We have more information about side effects and tips on how to cope with them.

What else do you need to know?

Other medicines, foods and drink

Cancer drugs can interact with medicines, herbal products, and some food and drinks. We are unable to list all the possible interactions that may happen. An example is grapefruit or grapefruit juice which can increase the side effects of certain drugs.

Tell your healthcare team about any medicines you are taking. This includes vitamins, herbal supplements and over the counter remedies. Also let them know about any other medical conditions or allergies you may have.

Loss of fertility

You may not be able to become pregnant or get someone pregnant after treatment with these drugs. Talk to your doctor before starting treatment if you think you may want to have a baby in the future.

Men might be able to store sperm before starting treatment. And women might be able to store eggs or ovarian tissue. But these services are not available in every hospital, so you would need to ask your doctor about this.    

Pregnancy and contraception

This drug may harm a baby developing in the womb. It is important not to become pregnant or get someone pregnant while you are having treatment.

Women must not become pregnant for at least 5 months after the end of treatment. Men should not get someone pregnant for at least 6 months after treatment. 

Talk to your doctor or nurse about effective contraception before starting treatment. Let them know straight away if you or your partner become pregnant while having treatment.

Breastfeeding

It is not known whether these drugs come through into the breast milk. Doctors usually advise that you don’t breastfeed during this treatment.

Other conditions

If you are having tests or treatment for anything else, always mention your cancer treatment. For example, if you are visiting your dentist.

Immunisations

Don’t have immunisations with live vaccines while you’re having treatment and for up to 12 months afterwards. The length of time depends on the treatment you are having. Ask your doctor or pharmacist how long you should avoid live vaccinations.

In the UK, live vaccines include rubella, mumps, measles, BCG, yellow fever and one of the shingles vaccines called Zostavax.

You can have:

• other vaccines, but they might not give you as much protection as usual
• the flu vaccine (as an injection)
• the coronavirus (COVID-19) vaccine - talk to your doctor or pharmacist about the best time to have it in relation to your cancer treatment

Members of your household who are aged 5 years or over are also able to have the COVID-19 vaccine. This is to help lower your risk of getting COVID-19 while having cancer treatment and until your immune system recovers from treatment.

Contact with others who have had immunisations - You can be in contact with other people who have had live vaccines as injections. Avoid close contact with people who have recently had live vaccines taken by mouth (oral vaccines) such as the oral typhoid vaccine. Sometimes people who have had the live shingles vaccine can get a shingles type rash. If this happens they should keep the area covered.

If your immune system is severely weakened, you should avoid contact with children who have had the flu vaccine as a nasal spray as this is a live vaccine. This is for 2 weeks following their vaccination.

Babies have the live rotavirus vaccine. The virus is in the baby’s poo for about 2 weeks and could make you ill if your immunity is low. Get someone else to change their nappies during this time if you can. If this isn't possible, wash your hands well after changing their nappy.

More information

For further information about each drug and the possible side effects go to the electronic Medicines Compendium (eMC) website. You can find patient information leaflets for each drug on this website.

You can report any side effect you have to the Medicines Health and Regulatory Authority (MHRA) as part of their Yellow Card Scheme.