12/5/19: Medical Oncologist Appointment

My medical oncologist appointments are usually on the same day as chemo treatments, but my doctor will be out of town tomorrow, so I got scheduled to see her a day earlier.

We went over my side effects. Every winter, the back of my hands get very dry, and I need to moisturize, moisturize, moisturize. This year, in addition to just being dry, I have a red, bumpy, itchy rash. My oncologist was confident that chemo is the culprit. Skin rash is listed as one of the many possible side effects of Taxol. She suggested a thick cream like Eucerin, or an ointment like Aquafor.

Regarding my hair, I told her I feel like Gollum from Lord of the Rings.

She said, "No! I won't let you think of yourself that way!" Instead, she suggested I think of myself like Jean-Luc Picard. In the past, she has also offered up young Sinead O'Connor as an example of a beautiful bald person.

 

Neither of those two fit, though, because I really do have straggly long hair like Gollum. Okay, that's an exaggeration. But at this point, the few strands of hair I do have aren't hiding the baldness at all. They just make it look worse. I didn't shave my head before because I was holding out hope that maybe I wouldn't really lose too much, like my aunt who had chemo years ago, whose hair thinned only enough that she noticed it, and others didn't. But now that I'm wearing a hat all the time in front of other people, there doesn't seem to be a point to not shaving it all off. I can't think of any redeeming value for keeping around what's left of my hair, especially when looking at it sparks the opposite of joy. If I shave it off now, at least my head will look uniform, and when the hair grows back, it'll come in all the same length. I'm going to think about it.

Anyway. Since I'm closing in on the end of chemo, I wanted to clarify how long I'll be getting Herceptin, the targeted therapy that I will continue to get via port infusions every 3 weeks after chemo ends. I thought I was supposed to get 1 year total, and I was trying to figure out whether or not the 3 months I already got at the same time as chemo count towards that 1 year. My oncologist said she thinks I'll get 17 more treatments, which works out to 51 more weeks, which is basically another full year. She said she would double-check and confirm the numbers, but really it doesn't matter. Whatever the treatment is, I'll just show up.

After talking about the Herceptin schedule, my oncologist also mentioned that after chemo ends, I'll start another part of my hormone therapy. At my first appointment, I remember she said I would be getting Tamoxifen. But today, she said "exemestane". I would not have been familiar with this word at all, except I just happened to do a lot of research over the weekend on my presumed Lupron + Tamoxifen regimen. I read these articles:

2018 ASCO [American Society of Clinical Oncology]: Aromatase Inhibitor Plus Ovarian Suppression Yields Benefit in High-Risk Premenopausal Patients With Breast Cancer

Adjuvant Endocrine Therapy in Premenopausal Women with Breast Cancer (From the web site of The National Center for Biotechnology Information, a part of the United States National Library of Medicine, a branch of the National Institutes of Health.)

Basically, for hormone therapy in pre-menopausal women with ER+ (estrogen receptor positive) breast cancer, there are three options:

1. Tamoxifen. This is a pill that blocks estrogen from binding to estrogen receptors in breast cancer cells. Tamoxifen is generally considered standard treatment.
2. Ovarian Suppression (OS) + Tamoxifen (T). My pathology showed that my cancers are strongly (>95%) estrogen positive, which means the cancer cells feed off estrogen a lot. I am getting ovarian suppression via monthly Lupron shots. The ovaries are the main source of estrogen in the body, so suppressing them (via a chemically-induced menopause) drastically reduces the amount of estrogen in the body. Other parts of the body still produce a little bit of estrogen, so Tamoxifen is still needed to block whatever estrogen is present. This is the regimen my oncologist mentioned at our first meeting.
3. Ovarian Suppression (OS) + Aromatase Inhibitor (AI). Aromatase is an enzyme that is needed for the body to produce estrogen. An aromatase inhibitor, like exemestane, stops the production of estrogen in the body. With Lupron suppressing the ovaries, and exemestane stopping the production of estrogen from other sources, there is no longer any estrogen in the body to feed cancer cells with estrogen receptors. This is the regimen my oncologist brought up today.

In discussing OS+AI, my oncologist straight up said, "Women hate it." I appreciated her honesty, though I was already familiar with the sentiment from my own research. From what I've read, there are so many potentially debilitating side effects from OS+AI that quality of life can be drastically reduced. A lot of women choose to stop taking an AI because they just can't stand it. But, it is the most aggressive treatment that has the highest likelihood of preventing recurrence. 

The articles also point out that the studies show that the benefits of OS+AI hold true only for women at "high risk" for recurrence; there doesn't seem to be any added benefit for women at "low risk". Again, I'm in that grey "intermediate" area. The fact that I'm getting chemotherapy at all nudges me into the "high risk" category. I'm not very young (< 35 years old), but I'm still considered "young", which is another risk factor. My tumors were small, but I had 3, so my body has some kind of environment conducive for cancer growth. I guess it's enough for my oncologist to want to err on the side of caution, and pursue the more aggressive treatment.

It occurs to me that if I'm recommended for the most aggressive treatment, and if side effects really are unbearable, I can always switch to Tamoxifen. It may not be as effective, but it's still effective. Tamoxifen, of course, has its own list of side effects, but apparently they tend to be more manageable than those from aromatase inhibitors.