Robert A. Buckman, M.D., Ph.D.
Adjunct Professor, Behavioral Science
The University of Texas M. D. Anderson Cancer Center
Dr. Buckman:
Well, actually the situation's
quite straight forward. The breast cancer has a very high chance of
being sensitive to hormone blocking pills. In your particular case it
wasn't particularly aggressive under the microscope, so there is no
doubt what the recommendation is. We should start you on tamoxifen
pills straight away and keep them going for several years.
Mrs. Adler:
No. Absolutely not. I will not take tamoxifen.
Dr. Buckman:
You will not take tamoxifen?
Mrs. Adler:
No, I'm sorry but I'm just not...
Dr. Buckman:
You're not going to do it?
Mrs. Adler:
...impressed with that at all.
Dr. Buckman:
Okay, Mrs. Adler, let's take it back one stage. Tell me why you don't want to take tamoxifen.
Mrs. Adler:
Well, I did some research on it recently...
Dr. Buckman:
Okay.
Mrs. Adler:
...over the Internet. And I wasn't very impressed with the results that I was reading on the paper.
Dr. Buckman:
Okay. Tell me about those. Tell me what you got from the Internet
that's brought you to the "I'm not taking tamoxifen" stage? Because it
does happen quite commonly.
Mrs. Adler:
Well, the major problem was the cancer of the uterus.
Dr. Buckman:
What did you read about that?
Mrs. Adler:
I read that it can cause cancer of the uterus and I read that you can die from that.
Dr. Buckman:
Okay. Is it okay if I go ahead and
address that? Because obviously a lot of people are reading that in the
newspapers, see it on television, a lot. People like yourself Mrs.
Adler, get it from the Internet: "Tamoxifen causes cancer of the
uterus. Don't touch it."
Mrs. Adler:
Right.
Dr. Buckman:
Okay, let me do 2 things. Let me first talk about cancer of the uterus:
cancer of the endometrium as it's called. And then let me talk about
balancing the risks of cancer of the endometrium versus the cancer of
the breast coming back. First of all, there is an increased risk of
developing cancer of the endometrium from tamoxifen. In the patient
who's been past the menopause - like yourself, so after menopause - we
are very aware of that. And if there is any bleeding from the vagina
after menopause, we investigate it immediately.
We send you to a gynecologist and they take a specimen of the lining of the uterus and in a majority of cases it isn't cancer, but it's an abnormality in the lining. In a few cases, it is cancer of the endometrium and in the great majority of those cases investigated early, it's cured by surgery: by removing the uterus. Now removing the uterus is not a trivial issue, but the idea that, as it were, cancer of the endometrium is somehow high chance of being fatal, no it isn't. So, early detection and treatment are very, very possible. But this is the really important point. None of the newspaper reports or as far as I know the Internet reports, ever say if you have had breast cancer, the risk of the breast cancer coming back if you don't take your tamoxifen is very high compared to the small risk of cancer of the uterus. That's a complicated thought. Is it making sense?
Mrs. Adler:
It is making sense.
Dr. Buckman:
So that's the point: that the
cancer of the endometrium risk is small compared to the risk in your
case of the breast cancer coming back. So, have I answered that one?
Does that make sense to you?
Mrs. Adler:
I'm still not having it. I still am not having it. I'm dead against it.
Dr. Buckman:
What else are you...?
Mrs. Adler:
There must be some other way.
Dr. Buckman:
What else have you read apart from the cancer...?
Mrs. Adler:
Well, these hot flashes which I've
already been there and I don't really want to experience that again. It
was nasty as it was. And...
Dr. Buckman:
Okay...
Mrs. Adler:
...cataracts, all sorts of different things.
Dr. Buckman:
Well, should we talk about the hot
flashes because you are right? Your hot flashes were bad when you had
the menopause Mrs. Adler?
Mrs. Adler:
Yes.
Dr. Buckman:
Okay, well tamoxifen, as it were,
re-evokes the hot flashes of your menopause and they might be bad if
they were bad at the time of menopause on tamoxifen, but there are 3 or
4 medications that we can try which may control the flashes
dramatically: may reduce them very dramatically. If they don't, if
those medications don't work, then we can sit down - you and I - and
discuss picking another anti-estrogen treatment -- not tamoxifen:
another one from the shelf. Tamoxifen will be the first choice because
it's got a very good track record. But the hot flashes are a problem we
can approach and probably fix. If we don't, then we can change from
tamoxifen to something else. Now, how do you feel now?
Mrs. Adler:
Well, I feel a little bit better about that, but I'm still not sure.
Dr. Buckman:
Because?
Mrs. Adler:
I just don't want to have to think about what might happen when I am on it.
Dr. Buckman:
What's going on there? What do you mean...?
Mrs. Adler:
Well, I have a new partner and I'm a bit shy of introducing a sexual relationship with him because of my vaginitis problem.
Dr. Buckman:
Okay.
Mrs. Adler:
And I understand that the tamoxifen aggravates the vaginitis as well so
I don't really want to get into this until I know that it can be fixed.
Dr. Buckman:
Okay.
Mrs. Adler:
So it makes it a problem for me, for my new relationship.
Dr. Buckman:
Okay. Now this is obviously a very
delicate issue. And as you say, you're a shy person. Is it okay if we
do talk about it for a moment or two because I may be able to make you
feel quite a lot better? Is that okay?
Mrs. Adler:
Sure. Certainly. Go ahead.
Dr. Buckman:
Okay, vaginitis after the menopause
is very common because the lining of the vagina lacks estrogen and it
becomes thin and easily breakable and sometimes causes pain and
bleeding and makes intercourse very difficult. And you are absolutely
right that in many cases - in some cases and even many - that problem
becomes worse on tamoxifen. But I'll ask you a couple of delicate
questions. Have we talked or have you tried different kinds of
lubricants that may make things easier or is that...?
Mrs. Adler:
No, I haven't. I haven't investigated that yet.
Dr. Buckman:
Okay.
Mrs. Adler:
So that's another reason why I am here is for you to help me with solving this problem.
Dr. Buckman:
I think I can. We can organize some
sexual counseling and in particular concentrate on the use - the
physical use - of lubricants and so on. If when you're on the
tamoxifen, the problem does - despite the lubricants - become worse it
is possible to use estrogen creams while you're on the tamoxifen
because even if the estrogen did get absorbed in small quantities, it's
blocked by the tamoxifen: so it's safe.
So there is a lot we can do there. So we've talked about cancer of the endometrium, balancing the risk versus the breast cancer coming back, hot flashes, probably fixable to a large extent with different medications and we could select another tamoxifen-like agent, and then this very important thing about the vaginitis which we've got an approach to. Now is there anything else in the back of your mind? Is there anything else you've read on the Internet?
Mrs. Adler:
Oh just the blood clotting, the
cataracts, the whole combination of things, and then having to take one
pill for this thing and one pill for another. How many medications
would I be on if I'm trying to combat the effects from the tamoxifen?
Dr. Buckman:
At this moment, I don't know. At
this moment, what I would recommend is that maybe you could think about
everything I've said for awhile. Maybe we could meet next week? And you
could even bring your partner if you wanted to and we could talk about
that. See what side effects are a problem in your particular case and
address them, but it strikes me that the vaginitis problem with your
new partner was a really big issue.
Mrs. Adler:
It is a big issue. It really is.
Dr. Buckman:
Maybe that's the one we should sort
of concentrate on and if we can get that beaten and the symptoms right
down and everything is okay, then we're probably going to be alright.
Does that make sense?
Mrs. Adler:
I think I could go home and talk it over with him.
Dr. Buckman:
You could.
Mrs. Adler:
I'll break it to him gently and perhaps we could come back and see you together.
Dr. Buckman:
I'd like that. Okay, well you think
about it. Talk about it with your partner. And we'll meet again next
week, and I'll address any other questions that occur to either of you
when we meet next week.
Mrs. Adler:
Certainly.
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