This past week marked my 5 year “cancerversary”; April 26th was the date of the operation that made me cancer free. It is also, coincidentally, my actual wedding anniversary and for me personally, it’s been enjoyable to celebrate both on the same day.
But the 5 year mark for many women is significant. Most breast cancer survivors (with hormone receptor positive tumors) will need anti-estrogen therapy in the form of either tamoxifen or an aromatase inhibitor, and the recommended duration is a minimum of 5 years. So part of me thought, woo hoo! Toss that bottle of tamox in the garbage! But then another part feels I’d be giving up too soon, as many studies now suggest 10 years is better than 5. And another part feels almost scared to go off of it, ever, as though I would be losing a security blanket in a sense.
As most physicians will do, I take the approach of the risk/benefit ratio when trying to make clinical decisions relating to my patients. For some reason, it’s not quite as easy to do with my own health. I take into account side effects; I did have fairly miserable hot flashes the first few months taking it, and still do, from time to time. I feel as though my joints are a little more creaky and less flexible than before, but that could also be simply aging and the fact that I am approaching 50. But all things considered, I feel quite well, I don’t have major side effects, and so I should probably continue taking it, says my physician brain.
My patient or “person” brain also takes into account other, almost silly or random factors. For the past 5 years, if I forget something around the house such as signing a form for my kid’s school, I blame tamoxifen. If I have a terrible night with a bout of insomnia, I also blame tamoxifen. Hot flashes? Mood swings? You get the picture. And I was more than happy to have instant cessation of my monthly visitor on this drug.
Add to this the fact that for some odd reason, with my insurance, tamoxifen has no co-pay. My blood pressure medication is $30 for a three month supply, but tamoxifen, zero! Who knew! While this might seem like a small thing, I have plenty of patients who decline to fill a needed or helpful medication simply due to the cost. Getting this medication for free for almost five years is a nice provision; maybe it’s a sign from above that I should stay on it. I have one patient in my clinic who is in her 70s and has been on tamoxifen for over 20 years; interestingly, she is married to a retired Oncologist. I might just be “that gal” someday…
Ironically, on this very same day known as cancerversary, I had a virtual visit with a patient of mine who is also a physician and a breast cancer survivor. She has completed three years on an aromatase inhibitor, known as arimidex. But her side effects are much more significant than mine, including fatigue, joint pain, insomnia, and importantly, changes in her weight leading to central obesity and actual development of diabetes and the metabolic syndrome. She was astutely asking about the risk benefit ratio of stopping the drug, versus continuing it. It was difficult for me to find actual data in the literature regarding this scenario, so I estimated a “best guess” in terms of her stage and oncotype score. Still, it wasn’t clear to either of us what to do next, so I advised an appointment with her treating oncologist.
I am sure many readers have grappled with these same issues; it could be cancer treatment, or blood pressure medication, or cholesterol lowering drugs. The risk/benefit ratio, while it seems like it should be clear cut, is often murky at best. I’d love to hear what factors into your medical decision making, both scientific and personal.
And here’s to five more years…