How do you solve a problem like tamoxifen?

I take it and don't think about the side effects very often because I can't bear to. The oncologist said to take it so I take it. I know there's a chance of developing endometrial cancer, so I get checked out by the Smooth Gynecologist Who's Younger Than I Am But Acts Like She's Older. What tamoxifen does seems so direct: It cuts off the absorption of estrogen, which is what my tumor grew on. In August the New York Times told us that tamoxifen can cause the formation of a non-estrogen-sensitive and hard-to-treat tumor. And Tuesday's NYT tells of omission bias, a term for the phenomenon whereby a person worries more about a low risk of harm from something they do than about a higher risk of harm from doing nothing. In the story, the worry was about tamoxifen. The Times reported that women are afraid to take the drug. Out of 632 women in a study, 80 percent said they were worried about side effects, and most of the women said they wouldn't take tamoxifen.
At rowing practice (indoors) Monday night someone was complaining about tamoxifen's side effects, including weight gain. I feel like a fool to take it. But the good it can do is significant. Though now I read now that there's a chance of cataracts and blood clots. My polycythemia vera puts me at risk for clots, and I take hydroxyurea for the p. vera, even though the drug could cause leukemia, because the condition itself could cause leukemia, and my inhaled steroid for asthma could combine with my other drugs to make me even more liable to develop blood clots. But the hydroxyurea lowers my red blood cell count, which makes me less likely to have a clot. Red blood cells are those round red spheres in the image above.

It is a difficult, difficult thing to be alive.

The papers pile up and the news gets worse and there's another surge, the world is dangerous and the wind chill here at the moment is four below. The house is creaking from the cold. I'm wearing a flannel nightgown from Austria and L is asleep between flannel sheets with sketches of snowmen on them.

On the one hand, on the other hand, on the other other hand.

[shrug image from dreamstime.com]

More from the Annals of Polycythemia Vera

L's office brings in people to test our blood every year in a "wellness screening." I have polycythemia vera, that in layman's terms means I have too many platelets. (I want to link to earlier posts about PV but the linker isn't working. See 2/20/08, 3/9/08, 6/2/08, 2/1/09.) I sent my results to my hematologist yesterday and today she said that since my platelet counts are still high, despite my therapeutic phlebotomies (I go to the blood bank and they remove a pint and throw it away) that she wants to talk about prescribing hydroxyurea to lower the count. Wikipedia tells us that it's "used in hematological malignancies, specifically polycythemia vera and essential thrombocytosis." Whether my PV is cancer or not depends on whom you talk to. The delightful thing about hydroxyurea is that it prevents leukemia and also can cause it. It gets you coming and going. Side effects include "drowsiness, nausea, vomiting and diarrhea, constipation, mucositis, anorexia, stomatitis, bone marrow toxicity (which may take 7-21 days to recover after the drug has been discontinued), alopecia (hair loss), skin changes, abnormal liver enzymes, creatinine and blood urea nitrogen." For the moment I'm not upset, just scared about adding this new drug to my large bouquet of strong medicines. Will I have to take more drugs to combat the side effects of hydroxyurea?

The FDA tells us that the drug is good for ovarian cancer. I wonder if you can use it pre-emptively. Would that be the silver lining in this cloud? Likewise, what if people took chemo and they didn't have cancer? I suppose the chemo would kill off any cancer cells swimming below the radar. But it wouldn't keep you from getting cancer later.

Mayo tells us we should wear disposable gloves when handling the tablet or capsule. After all, this is a substance that can turn your nails black, cause hallucinations, and as I said, bring on leukemia--even years after you've stopped taking the medicine. It can lower your white blood cell count, so make you more susceptible to infection.

On the other hand, it can cause weight loss.

The thing about polycythemia vera, or at least my version of it, is that the symptoms are ridiculous. I have tiny red dots on my skin and I get very itchy from being in hot water or even from the deep massage I'm getting for my Achilles tendonitis or even just out of the blue. It also gives me red cheeks so I look robust and healthy, like I've spent all day skating around the frozen-over dikes with Hans Brinker.

I felt fine before I was diagnosed with cancer two years ago, and I feel fine now and I keep thinking of Ann Patchett's book, Truth & Beauty, where she quotes Lucy Greely saying that her cancer made her feel special. It's ridiculous now to feel special when one out of every eight or nine US women has a breast malignancy. But there's this Thanatos-loving part of me, or melodrama-loving part, that feels sort of hopeful about the possible endometrial cancer. And I don't mean hopeful as in, It's probably nothing. It's like this dark hopefulness, like an attraction to the edge of a chasm. As in, O, I'm even more special because I might have a different kind of cancer.

What kind of person thinks this? Do I feel another cancer is inevitable, so that it's a relief when I think of finally being hit by a second one? Then I don't have to worry about the second hit. If you're dying, you don't have to worry about dying, because you're already doing it. When I was younger I felt so guilty for being alive because I knew that if I didn't have asthma medicine I would be a goner. And I knew I was privileged to have the asthma medicine, and later a breathing machine, because there were people everywhere who weren't getting care. And maybe they were dying and maybe not, and it seemed like my real fate was to die. To be dead. (This is why I've been in therapy since the Nixon administration.) It helped that my parents paid for a machine like mine that they donated to the hospital. I went to summer camp for three years and hated it because I couldn't breathe but I didn't tell my parents, I think because I didn't want to disappoint them. There was something deeply wrong with me, I couldn't exist with and in Nature, even though it should have been... so natural. Nature could kill me, and now my own nature, my blood, has turned against me. Has thickened against itself.

We are finite beings. Is that so hard to fathom? Yes. Because we have been here our whole lives. The world could not have existed before we were born.