Tamoxifen

I'm going to try to update quickly on my appointment with Dr. Y last week during my Herceptin appointment, because it is changing my treatment plans. I need to be quick though, as I have another chemistry exam tomorrow and need to study!

Wednesday last week I saw Dr. Y when I was in for my Herceptin infusion. He started off by talking alot about Tamoxifenand encouraging me that he thinks I should take it.

In case you don't remember any previous discussions, here's a brief overview of my history and the use of Tamoxifen. One test they do on breast cancer tumors if for estrogen (ER) and progesterone (PR) sensitivity. The cancer cells can have receptors that soak up estrogen or progesterone and that extra estrogen or progesterone can cause them to grow. My results were negative for progesterone and "focally weakly positive" for estrogen. This means that there were some spots on my tumor that had positive receptors, but not the whole thing and they didn't take in huge amounts of estrogen. There is a drug that is commonly prescribed when women are ER positive. It is called Tamoxifen and it is an anti-estrogen drug. Back when I was diagnosed, Dr. L had hoped I was ER positive because this drug does great things for stopping recurrence. It is also sometimes prescribed as a breast cancer prevention drug in high-risk patients. I did not want to be positive, because the common protocol is to take the drug (in pill form) daily for 5 years. During this time, I should not get pregnant. However, when my results came back initially, they were so faintly positive, that Dr. L told me they were negative. When we talked to Dr. Y for our inital consultation, he told me that in my case taking Tamoxifen would increase my survival rate stats from approximately 95 to 96%. If I were a strong positive it would have taken me from 95 to about 98%.

Fast forward. Over the past months, Dr. Y has mentioned Tamoxifen and that we'd discuss it later. I've done alot of thinking about it, and in my head, I was willing to give up that extra 1% of survival rate, to continue to build my family. I would love to start trying soon after I get the green light from Dr. L which will be in about 18 months.

Here were the benefits:
- Shown to decrease risk of cancer in other breast by up to 49%
- Lowers risk of osteoperosis
- Gives me back that percentage point on the survival rate

And the drawbacks:
- With a "focally weakly positive" diagnosis, I get limited benefit
- No pregnancy while taking
- Increased risk of endometrial cancer
- Menopausal type symptoms (hot flashes, vaginal dryness, mood swings)
- Increased risk of blood clots (heart attack, stroke, etc.)

I told him that while I didn't want to be selfish and risk my health, at the same time, continuing my family is important to me. My current plan for baby #2 would be the perfect timing for my med school plans. If I do 5 years of Tamoxifen, I would be right in the middle of med school before I got the go ahead, so I would want to wait until I was done, so now we're looking more at 7 or 8 years until I would get pregnant. I know people have kids at age 35, but I'm not sure that I want 9 years between my children. It seems like a lifetime. He asked what my plans were for having children. I told him, God-willing, I would get the all clear at the 2-year mark (Sept. 2007). Due to my class and M-CAT plans, I would wait until January 2008 to start trying to get pregnant. He told me that my risk of recurrence is front-loaded, meaning that I have a higher risk of recurrence the first 2 or 3 years. He thought for a moment, and then told me, "I'll take it." So, we compromised. I'll take the Tamoxifen for the next 20 months or so, and then if all doctors agree, I can stop it and get pregnant. I asked if it is safe to stop and get pregnant immediately and he said it leaves your system within 2 weeks.

Next we discussed the possibility of removing my ovaries when I'm done having children. This is still a theoretical discussion. I'd like to get the genetic testing done first and see if I really have an increased risk. His view was that Ovarian Cancer is extremely hard to screen for. There isn't an easy way to catch it early, so most people aren't diagnosed until Stage 3 or 4 and by then it's almost too late. I agree it sounds nasty and if the testing reveals I'm at an increased risk, I'll gladly give them up in a few years. Although, if there isn't any proof that I'm at risk, I'm not sure how eager I am to go into menopause in my 30's and permanently shut the door on future children (I'm not entirely sure 2 is enough for me). So, we'll continue to talk.

So, that was a heavy appointment. I'm happy with my decision and very glad that my doctor was willing to spend the time to talk about it rather than just writing me a prescription. This is also a decision that can remain flexible. I've started the drugs (day 3 now), and maybe in 20 months we'll all decide that I'm not ready to get started on baby #2 and then I can continue on the regimen. We'll just have to wait and see what God has in store. If anything, you'd think I learn that I can't make all the plans for my life!

Ok, time to go study!