Preventative Care in the Age of COVID-19

Obviously, preventative medical care has taken a backseat to responding to COVID-19 and this is entirely the right decision. Our medical system needs to focus its’ resources right now on those that need help the most.

I started seeing signs of this last week when I went in for my birth control appointment. As I was sitting in the waiting room for my appointment, the receptionists were calling patients who were scheduled to come in for non-urgent appointments and pushing all of the appointments out until May. At the end of my appointment, my doctor told me to come in a month from now for the follow-up checkup. When I called a few days later to schedule that appointment, I was told it would need to wait and they would call me back. To be honest, although the appointment is standard (I had the Paragard IUD inserted, so there’s usually a check-up just to make sure all is well), it is definitely something that could not happen or could happen via telemedicine. I’m not too concerned about the appointment and I would prefer that we keep as many people out of the building that my appointments are in as possible, as the building has a lot of high-risk patients traveling through it.

Because of these types of measures, I’ve decided to stick with my current breast cancer center for now. I called into my breast cancer center this past week and informed them that I had completed all of my pre-Tamoxifen steps, as discussed with my previous doctor, and that I was wondering if they could give me the prescription without me having to come in for an appointment. They told me that their new doctor, who will be replacing my old doctor, would be starting in early April. Since I had recently been in to see my old doctor, I could meet with the new doctor via telemedicine and she would likely give me the prescription to start my meds.

Additionally, my primary care physicians office also very quickly shut down their office and switched predominantly to a telemedicine model. While they are still taking patients in the office, they are being very particular about who is allowed to come into the office to ensure they do their part to minimize the transmission of COVID-19.

I do think it is great that telemedicine standards are being changed right now. Telemedicine is a huge tool that can help so many people “see” their doctors more often while not having to take so much time off work or travel, which can be very difficult for some people. One of the mental illness podcasts I listen to once time described situations where people spent an entire day traveling to see their doctor, because they relied on public transportation and the only route was a multi-hop route that took hours. Telemedicine is a great tool that can be used to help with these issues. I hope that the government and insurance companies keep the new standards so that telemedicine can become a regular part of our healthcare system.

In the meantime, everyone please do their best to keep everyone healthy right now. Follow your state and local government’s guidance.

Bilateral Ultrasound and Results

Earlier this week, I had my bilateral ultrasound. I’ll go ahead and give the spoiler alert- everything came back as benign!

I got my ultrasound at the same radiology center that I got my mammogram and my MRI, so the initial routine was pretty similar. Go into the center, sign in, wait for awhile, sign a few forms, wait for a while, and then go back to the locker area. I changed into the gown and locked my things up (although, in the days of COVID-19, I’m thinking this joint locker system is a bit of a shortfall, especially in a situation where people can have compromised immune systems). I then got called back into the room.

Many women are already familiar with ultrasounds due to the pregnancy thing; this was a pretty similar situation. I laid down on a table, where they then put gel on my chest and used the magic ultrasound wand to locate the nodes previously identified through both my mammogram and MRI. In order to enable this, I was asked to either lay flat on my back or slightly on my hip leaning to either side. This got a little uncomfortable, as I was in this position for maybe a full five minutes, but nothing huge. As I was getting an ultrasound on both breasts, they first focused on one breast and then moved to the other.

Before starting the ultrasound, the technician surprised me by saying that the doctor would review the results immediately after the exam and I would have an answer before I left that day. That is super awesome! So, true to her word, after the ultrasound was complete, she left to go talk to the doctor. She came back maybe ten minutes later, informing me that everything was benign, which was good! Similar to the results from the MRI, it looks like all the nodes are fluid-filled cysts, which are nothing to worry about. They don’t cause any increase to my cancer risk and don’t normally require any follow-up care at all (unless they are painful, in which case they can be drained).

With that, I headed home!

Up next on my journey, I still need to switch birth controls, which is happening next week. As a reminder, I’m switching birth controls because my current medication maybe but maybe won’t cause the Tamoxifen to be less effective. There’s not really any reason to risk this, so I’m just switching to a different medication that has no concerns in this area.

I still have to get tested for my BRCA genetic mutation. I’m a bit frustrated in this area; I’ve had this appointment rescheduled twice upon requests from the office, with my current appointment being in mid-April. I don’t have to get my BRCA results back before starting the med, so that shouldn’t really be a problem, but it’s frustrating nonetheless.

Last, on Monday I’ll work to schedule an appointment with my new breast cancer specialist. We’re getting closer!

Change in Meds: Birth Control

One of my action items before I start taking Tamoxifin is to switch from Mirena to a different birth control. The reason for this is that the research isn’t super clear on whether or not taking Mirena while on Tamoxifin would possibly inhibit some of the positive benefits of Tamoxifin. So just as a precautionary measure, I’ll be switching birth control methods.

I recently met with a new gynecologist to initiate this change. The truth is that I haven’t had a dedicated gynecologist for years now, as my primary care physician does well-women visits, so I usually get my pap smears, etc, at my annual exams. However, I do need to see a gyno to get the Mirena IUD removed, so I figured I would just head directly to a gyno for my new prescription.

After chatting briefly with the gyno, he recommended that I either use Paragard, which is a copper IUD, or just get my tubes tied. One weird thing about both of these options is that, for the first time since I’ve been 18, I won’t be introducing unnecessary hormones into my body to regulate my period flow (Paragard is hormone free.) I’m happy about that, but also terrified at what a non-hormone regulated period will look like. This could be horrible.

After doing some thinking and talking things over with my husband, I’ve decided to go with the Paragard. It will be a bit of time before I can make the switch, as insurance needs to sign off on it and whatnot. I’m not looking forward to the day it goes in. My experience in getting my Mirena placed was a very crampy experience that required a follow-up ultrasound to make sure the Mirena wound up in the right place and would do its job. However, Paragard checks off all the boxes. Also, there are way fewer side effects with Paragard than with Mirena! I won’t bore you with the side effects, but you know where you can find them if you really want to *wink*.

Some Basics

During my last appointment with my oncologist, she provided me with recommended organizations for some questions that I had regarding the use of Tamoxifin. One of these resources is the NIH’s National Cancer Institute. As my blog is following the preventative steps I’m taking to reduce my breast cancer risk, I thought I would talk a little bit about my own risk factors and protective factors. While I’m doing this, I’ll be working off of information provided by the National Cancer Institute at this link.

First, my risk factors. I have an inherited risk of breast cancer, with my mother, my maternal grandmother, and my maternal great-grandmother all having breast cancer at some point of their lives. Specifically, my mom got breast cancer at the age of 46. Since I am 36, this puts me within the 10-year window where I’ll start getting mammograms a bit earlier than other women.

Second, my breast density is a level c, which is heterogeneous. According to the American Cancer Society, there are four levels of breast density, which describes the proportion of fatty tissue to dense glandular and fibrous tissue. This is an area where I could stand to do more research.

As of right now, I’m not considered to have extra exposure of breast tissue to estrogen made in the body, as I didn’t start my period until after the cut-off date (which is age 11). However, if I wind up going into menopause at a later age than is determined standard, my risk could raise in this area.

Technically, I am a little obese. This is a hard thing to say, because people generally consider me a thin person. However, the gym I go to has an InBody scanner and I recently did my first scan. According to the test results, I definitely have a visceral fat issue. This isn’t a surprise to me; I’ve always gained my extra weight around my hips and waist. I also just weight more for my frame than I should. I’m pretty short, but I eat fries and cheese like I’m much taller.

Lastly, I do drink alcohol, although certainly not very often and not in large quantities. At this phase of my life, I’m probably having maybe a few glasses a month, although during vacations that might in increase to a glass at dinner each night.

Okay, now let’s move to protective factors. The first that I benefit from is reducing exposure of breast tissue to estrogen. Because of my family history of breast cancer, my doctors have always been really awesome at working with me to find birth control that is at lower estrogen levels. I also breast-fed my daughter for about 10 months. To be totally transparent, I pumped for 10 months and she drank the milk from a bottle. I’m firmly in the camp of feeding your infant in whatever form works best for you and your family, as long as your infant is getting the nutrition they need, which can come from breast milk or formula, straight from the source or in a bottle. You do you and your family.

The second is the fact that I exercise. My exercise has been hit and miss in the past, but in the past six months or so, I’ve been pretty good at getting in 5-6 days of exercise a week, doing a combination of strength training/cardio or HIIT/yoga.

The one protective factor I haven’t taken advantage of is SERMs, or selective estrogen receptor modules. Tamoxifin is a SERM, so I will be taking advantage of this protective factor once I finish my course of medication.

Everyone’s risk and protective factors vary, so I definitely encourage you to visit the link in the first paragraph to check out what your personnel risk factor might look like. Also, the best way to have this conversation is to talk to a doctor, so definitely do that as well. As I’ve mentioned in previous posts, I meet with my doctor on a schedule that we have decided is best for me and we discuss all of these things at my appointments, so I’m not coming to these conclusions based solely on internet research, but rather through a history of dialogue with my primary physicians and oncologist.

Fast Forward To Today

A few weeks ago, I returned to my oncologist for a check-up. I had not been to see her for about a year and a half. Prior to this break, I had gone in for my first mammogram in order to establish a baseline after I had completed breastfeeding my daughter. Although my husband and I are now firmly in the camp that we will only have one child, at the time there was some chance we might have a second child and there are some changes that can take place in the breast as a result of breastfeeding. Because of this, my doctor thought we should go ahead and do a baseline if I was prepared to do so.

My first appointment after this break was in January 2020. During this appointment, my oncologist re-ran my IBIS risk evaluation, v8 stats. You can find out more information about this evaluation tool here. According to my test results, my person risk of breast cancer after five year is 3.1%, while the general population has a risk of .3%. My lifetime risk is 41.2%, while the general population has a risk of 13.2%. Because my personal risk level is of a certain level higher than the general population, I continue to be a candidate for preventative measures, to include taking Tamoxifin.

While I previously was not interested in taking Tamoxifin, seeing the new stats and being in a different phase of my life has changed my view. While I previously was told I would need to take the drug for ten years, more recent research has led to the timeline for preventative use being only five years.

However, there are a number of steps I’ll be taking before starting to any medication. First, after discussions with my oncologist, I will be getting both a mammogram and an MRI. In addition, I have decided to meet with a gyno to switch the IUD that I have in. After my daughter’s birth, I decided to adopt Mirena as my birth control mechanism. However, earlier it was believed that taking Mirena while on Tamoxifen would reduce the effectiveness of Tamoxifen. Although some of the more recent studies show that it might not be quite as big of a concern as it originally was, I would prefer to switch to an IUD that has none of those concerns, which may be a bit irrational but sometimes that’s how these decisions are made. In addition, I also need to stop taking Benedryl as a sleep aid, as you can’t take Benedryl and Tamoxifen at the same time. I started taking Benedryl as a sleep aid when I was pregnant (although not while breast-feeding), since melatonin isn’t an option while pregnant. I’ve stuck with Benedryl because it’s a regulated medicine (melatonin isn’t, unless you get it through prescription, which I don’t) and I also just sleep better on it. It’ll probably take me a bit of time to find a replacement for the Benedryl.

Lastly, I am going to meet with the genetic counselor again and finally get tested for the BRCA genetic mutation. I have two reasons for doing this. First, I have a daughter and I want her to have all the information possible to make her own decisions. Second, according to my doctor, as the medical research gets further along, the findings from the BRCA genetic mutation testing begin to provide you with more detailed health information. I don’t have more specifics on that, but I’m guessing I’ll find out more when I prepare to get the testing done.

I am a bit worried about some of the side effects of Tamoxifin, which include things like hot flashes, nausea and possible weight gain. However, many of the stories I hear about the side effects are coming from women who are taking Tamoxifin after being treated for breast cancer, so I’m not entirely sure how women taking it for entirely preventative purpose fare. Thus… my blog! Fingers crossed!