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Bad combination for breast cancer patient: Too much fear, too little trust

My car was towed. It happens. A few more unfortunate situations later, and I was crying. It wasn’t that I was feeling sorry for myself. I was just mad, and the tears wouldn’t stop.

I didn’t feel comfortable talking to a friend at the moment, so I grabbed my phone and called the Y-ME National Breast Cancer Organization’s 24-hour hotline. I had saved the number (800-221-2141) on my phone when I was diagnosed in August, but I had never used the free service before. I should have.

“Before, I would have just fixed the problem, and that was that. Tears were never an option,” I told the woman named Lauren who answered my call.

The kind stranger, who survived breast cancer 12 years ago, gently turned my focus back on a plan of action. I needed to drink a glass of water. And commit to asking for help to cope with my fears.

“You are not overreacting. It’s completely normal for you to feel this way,” Lauren said. “It’s going to be a difficult transition. You are going to need help.”

I’m extremely independent, so I don’t like asking for help. I don’t trust easily. And I have been extra fearful lately. The more afraid I am, the more I want to know. And this sometimes works against me.

My current fears have to do with Tamoxifen, the anti-tumor drug my oncologist has prescribed. I felt the need to read about other drugs and genetic variations that interfere with Tamoxifen’s power to neutralize estrogen, which can feed breast-cancer cells. It made me wish I was an expert in pharmacogenetics, the study of genetic variations that affect patients’ response to pharmaceuticals.

Human liver enzymes are supposed to metabolize Tamoxifen. Two enzymes (Cytochrome P2D6 and YP3A) are responsible for changing it into a chemical called Endoxifen. And for the drug to work, the enzymes have to do their job. Endoxifen is then supposed to bind to estrogen receptors to prevent or slow the growth of breast cancer cells.

A few years ago the American Society of Clinical Oncology and the Food and Drug Administration’s Clinical Pharmacology Subcommittee attributed Tamoxifen’s failure in some patients to a genetic variation (of the CYP2D6 gene), and deemed it an important predictor of the drug’s efficacy. Some doctors were requesting genetic testing before prescribing the drug.

In 2010, however, researchers presented data from two clinical trials at the San Antonio Breast Cancer Symposium that showed women who had the genetic variation were not more likely to have a recurrence. Soon after, an editorial in the Journal of Clinical Oncology said that there was a “hesitancy and uncertainty about (CYP2D6) genetic testing in clinical practice.” My oncologist did not prescribe the test. And that seems to be in line with current research.

Drug interactions can also affect the way Tamoxifen is metabolized, and when I learned that two medications I was taking for depression and anxiety, Buproprion and Escitalopram, were on a red list as having “high” and “moderate” impact on the efficacy of Tamoxifen, I did something foolish: I abruptly stopped taking them without discussing it with my doctors. It was a mistake on both counts — patients are almost always taken off these drugs gradually — and probably explained my crying episode.

When I talked it over with the doctor who had prescribed the antidepressants, M. Beatriz Currier, the director of the Courtelis Center for Psychosocial Oncology at the University of Miami, she told me my worries were overblown.

“When co-prescription of Tamoxifen with an antidepressant is necessary, preference is given to antidepressants that exhibit little or no impact on Tamoxifen’s metabolism,” Currier said.

“You have to trust us. We are familiar with drug interactions. We can look at all of the studies and make an educated decision that is medically appropriate.”

My low level of trust and high level of fear were proving to be a bad combination. It’s good to be an educated patient, but it’s bad to not communicate well with your doctors.

“There were many things that needed to change before the cancer,” Currier told me. “Now is the time to change them.”

She suggested that I commit to weekly sessions with a psychologist at the Courtelis Center. I will also be calling The Y-ME National Breast Cancer Organization’s hotline again.


Part 1: At age 33, I’m dealing with breast cancer

Part 2: Cancer treatment complicates dreams of pregnancy

Part 3: Hanging in when chemotherapy gets rough

Part 4: Tough surgery choices: Mastectomy vs. Lumpectomy

Part 5: Silicone implans are not the only way to go in breast reconstruction

Part 6: Rebuilding the breast from body tissue

Part 7: Body fat can be used to build breast

Part 8: Facing my fears after mastectomy

Part 9: Taking control of the fear that comes with breast cancer

Part 10: Doctor knows about being a breast cancer survivor

Part 11: Radiation therapy gives her hope

Part 12: Finding strength from others

Part 13: Facebook, medication help breast cancer patient deal with depression

Part 14: A new outlook on 2012

Part 15: Breast cancer patient faces genetic mystery

Part 16: Using diversion to cope with harsh reality

Part 17: After radiation therapy ends

Part 18: Friend’s breast cancer journey is not as fortunate

Part 19: Anti-tumor meds come with scary story

Part 20: Reentry into the world after breast cancer treatment

From the Editor: Journalist confronts cancer, takes readers along