And now for Celebrity Jeopardy!!

I love celebrity jeopardy.  Saturday night live just isn't as good as it use to be. Ahhhh, I love me some Sean Connery.  This is one of my favorite episodes...   Turd Ferguson!  I am starting out with this because I want to think about anything other than what I am about to write about.  I have so much research to do I feel like I am getting back to that feeling I had when I was first diagnosed...I'm back in college in a great lecture hall and WHAMMO --- Pop Quiz in Latin and your life depends on it!  It's kind of a weird sinking feeling.

In terms of sobering, reality biting news, I saw Dr. Hayden today.  Given that I am still on Xeloda she doesn't want to do my final reconstruction surgery until the beginning of next year once I have finished the pills.  Uhhhhhhh.  That means I'll be Betty-Lopsided-Boop for another few months.  At least the prosthesis I bought is realistic and amazing.  I'll be getting my $300 worth out of it since I will be relying on for a little while longer.  But that's not what is really bothering me.

My tumor is Estrogen Receptor positive.  That means Estrogen makes tumors grow. It also means I have to shut down Estrogen production in my body.  Lupron shuts down the production of estrogen in my ovaries and then tamoxifen (pending - more on this in a minute) will shut down estrogen production in my adrenal gland. Estrogen is pretty important in the female body and not just for sexual function.

To understand the roles estrogens play in women, it is important to understand something about hormones in general. Hormones are vital chemical substances in humans and animals. Often referred to as "chemical messengers," hormones carry information and instructions from one group of cells to another. In the human body, hormones influence almost every cell, organ and function. They regulate our growth, development, metabolism, tissue function, sexual function, reproduction, the way our bodies use food, the reaction of our bodies to emergencies and even our moods.

 The estrogenic hormones are uniquely responsible for the growth and development of female sexual characteristics and reproduction in both humans and animals. 

In women, estrogen circulates in the bloodstream and binds to estrogen receptors on cells in targeted tissues, affecting not only the breasts and uterus, but also the brain, bone, liver, heart and other tissues.

 Estrogen controls growth of the uterine lining during the first part of the menstrual cycle, causes changes in the breasts during adolescence and pregnancy and regulates various other metabolic processes, including bone growth and cholesterol levels.

Estrogen produced by the ovaries helps prevent bone loss and works together with calcium, vitamin D and other hormones and minerals to build bones. Osteoporosis occurs when bones become too weak and brittle to support normal activities.

Okay, so Lupron shuts down my ovaries and forces me into menopause.  But I DO NOT know if that means I am still considered pre or post menopause now since it is chemically induced. I think I'm still considered pre-menopausal due to the fact that production would resume off of the drugs. Additionally, the lack of estrogen from ovarian ablation weakens my bones over time hence the Zomeda infusion. 

Dr. Hayden suggested that I look into Arimidex rather than Tamoxifen, because Arimedex is more tolerable, less harsh on the bones, and was shown to be more effective in preventing recurrence in post-menopausal women. But I don't think I'm post-menopausal. Arimedex doe NOT work for pre-menopausal women. 

Both Arimidex and tamoxifen work by exerting an effect on estrogen, which feeds the majority of breast cancers and helps them grow. Arimidex belongs to a class of drugs called aromatase inhibitors, which limit the amount of estrogen the body produces in postmenopausal women. Arimidex works by preventing the conversion of steroids made by the adrenal gland into estrogen.

In a woman who has gone through menopause, the adrenal gland is the largest source of estrogen. Arimidex doesn't work in women who are premenopausal because their ovaries make most of their estrogen.

Tamoxifen belongs to a class of drugs called selective estrogen receptor modulators (SERMs), which work by blocking estrogen from binding to its receptors in the breast. This drug works as well in both premenopausal and postmenopausal women.

Are you following along?  I can barely keep up. I now have 13,568 questions for Philomena. 

Estrogen is the common link between most breast cancer risk factors, i.e., genetic, reproductive, dietary, lifestyle and environmental. It both stimulates the division of breast cells (healthy as well as cancerous) and, especially in its 'bad' form, increases the risk of breast cancer. Thus, hormonal drugs such as tamoxifen that block the effects of estrogen on the breast were expected to reduce the risk of breast cancer recurring in women treated for breast cancer. 

Tamoxifen acts as a weak estrogen by competing for estrogen receptors much as phyto-estrogens do. Like phyto-estrogens, tamoxifen has mild estrogenic properties but is considered an anti-estrogen since it inhibits the activity of regular estrogens. More accurately, tamoxifen is an estrogen-blocker. It fights breast cancer by competing with estrogen for space on estrogen receptors in the tumor tissue. Every tamoxifen molecule that hooks onto an estrogen receptor prevents an estrogen molecule from linking up at the same site. Without a steady supply of estrogen, cells in an estrogen-receptor-positive (ER+) tumor do not thrive and the tumor's ability to spread is reduced. 

However, tamoxifen exhibited two conflicting characteristics. It could act either as an anti-estrogen or as an estrogen. Therefore, while tamoxifen is anti-estrogenic to the breast, it also acts as an estrogen to the uterus and, to a lesser extent, the heart, blood vessels and bone. So, although it initially showed the tendency to counter breast cancer recurrence, it would soon be revealed that it also promoted particularly aggressive uterine and liver cancers, caused fatal blood clots and interfered with many other functions.

Unfuckingbelievable.  I'm not eligible for the better drug Arimidex so I have to take tamoxifen which can lead to more serious side effects like oh, um, aggressive uterine cancer? WTF. That leads us to the next topic of conversation with Dr. Hayden. My ovaries.  I wonder if I have an Oopherectomy if that means I am eligible for Arimidex?  Is that the best course of treatment?

Hayden thought I may want to have my ovaries removed but wanted me to talk to Philomena about it. Hayden suggests the less synthetic drugs in my system the better.  I have talked to Philomena about that and she seems to think it is up to me.  As if I have the benefit of years of studying and practicing medicine under my belt to make a heavy decision like that. Really? Even more alarming, I read that for young women with breast cancer being forced into menopause and removing ovaries at a young age can lead to shorter life expectancy and a host of other SERIOUS side effects and long term outcomes.  Oh yeah, I am not kidding.

Oophorectomy (removal of ovaries) is frequently done together with hysterectomy to decrease the risk of ovarian cancer. However, recent studies have shown that prophylactic oophorectomy without an urgent medical indication decreases a woman's long-term survival rates substantially and has other serious adverse effects, particularly in terms of inducing early-onset-osteoporosis through removal of the major sources of female hormonal production. This effect is not limited to pre-menopausal women; even women who have already entered menopause were shown to have experienced a decrease in long-term survivability post-oophorectomy. 

Here is an an excerpt from the study done on "elective" ovary removal:

• Objective. To review the data on long-term outcomes in women who underwent prophylactic bilateral oophorectomy, a common surgical procedure that has more than doubled in frequency since the 1960s.

• Study design. Literature review of the published data on the consequencesof prophylactic bilateral oophorectomy. Special emphasis was given to the Mayo Clinic Cohort Study of Oophorectomy and Aging.

• Results. There is a growing body of evidence suggesting that the premature loss of ovarian function caused by bilateral oophorectomy performed before natural menopause is associated with several negative outcomes. In particular, studies have revealed an increased risk of premature death, cardiovascular disease, cognitive impairment or dementia, parkinsonism, osteoporosis and bone fractures, decline in psychological wellbeing and decline in sexual function. The effects involve different organs (e.g. heart, bone, or brain), and different functions within organs (e.g. cognitive, motor, or emotional brain functions). Estrogen treatment may prevent some but not all of these negative outcomes.

• Conclusion. The potential adverse effects of prophylactic bilateral oophorectomy on heart health, neurological health, bone health and quality of life should be carefully weighed against its potential benefits for cancer risk reduction in women at average risk of ovarian cancer.

I made an appointment with Dr. Daly, my fabulous OB/GYN next Wednesday to discuss.  However, I don't see Philomena until October 12th.  That is way too long to wait and stew on all this information.  I'm going to try to move that up. I will need to bring two different people with me plus a tape recorder to RECORD the conversation so I can remember everything.  I feel like I've had the same discussion with her several times and each time it seems like new information and then I forget what she says.  I'm not going crazy though or losing brain cells.  Hayden told me that Lupron effects my short term memory. Anyway, are you feeling overwhelmed like I am yet?

I wish I could make these decisions neatly in a vacuum.  It just isn't possible.

Revised Schedule:

1. Totally 80's night Pool Circle at the Hollywood Bowl - tomorrow night
2. Weekend at a Villa at Pelican Hill in Newport Beach for Labor Day long weekend
3. Lupron Shot September 8th
4. Walk in Avon Walk September 16th-18th!!
5. Abby starts school September 19th
6. See Dr. Chung for ultrasound of right lymph nodes (the side I had the scare on just before the mastectomy) and general follow-up appointment late September
7. See Philomena October 12th.

I added the personal things in there for two reasons.  1) to show that I am forging ahead and starting to relive my life a little more like I was before and 2) to show how conflicting this all is.  Just when I feel I am gaining strides and looking towards the future I have to come back to reality that I will be living with cancer treatment for the next five years or more.  Two steps forward and one step back.