I’m at my appointment with the oncologist on 23 November. We agree I should go ahead two days later with my final session of chemotherapy. So far, so good, as it wasn’t entirely certain that that last sesssion would happen (What a difference a year makes).
The oncologist then goes on to say that I should start hormone therapy as “as soon as you’re up and about” after surgery. My operation is on 19 December (19 December – it’s official). I hadn’t really thought about when I’d start on that, but still so far, so good.
Then the oncologist asks if I can make an appointment with the dentist for the very next day. Now that throws me. Instead of trying to work out why I need to see a dentist, the only thing I can think of initially is who on earth gets a dental appointment at such short notice.
You’ll need to bear with me to find out the relevance of the dentist.
In my case hormone therapy (also called endocrine therapy) initially will consist of one tablet a day of a drug called letrozole. I’ll be on it for five years, and this will be followed by five years on another hormone therapy, tamoxifen.
Let’s focus on letrozole. This is used to reduce the risk of breast cancer coming back in post-menopausal women whose cancer is oestrogen receptor positive, or ER+. In breast cancers that are ER+, oestrogen supports the growth of the cancer. Post-menopausal women still produce some oestrogen and letrozole’s job is to stop the body doing that.
Now as we women of a certain age know all too well, a lack of oestrogen over time increases our risk of developing osteoporosis. To lower that risk in women taking letrozole, for example, a type of drug called a bisphosphonate may be prescribed. In lay terms bisphosphonates are called bone-hardeners or bone-tougheners. These drugs have been shown to have two benefits when used in the treatment of post-menopausal women with early-stage breast cancer. As well as decreasing your risk of developing osteoporosis, they have been shown to reduce your risk of developing bone metastases (tumours in the bones that result from breast cancer cells that have broken off from the original tumour settling in the bones and growing there) and improve survival.
The oncologist wants me to have a bisphosphonate called zoledronic acid while I’m on letrozole, initially every three months and then every six months. The idea is for me to have the first dose during my final chemo session. The oncologist says there’s “no urgency”, but suggests that since the first dose often causes “bone ache, joint discomfort and a ‘flu-like illness”, I might want to get “all the unpleasantness” out of the way before the next phase of treatment, ie surgery. There I was thinking I was to have three weeks’ respite between chemo and the op, but bring it on, why not?
Now we come to the part that involves the dentist. A rare side effect of zoledronic acid is a condition called osteonecrosis of the jaw. Now I don’t know about you, but I’m always wary of words with “necro” in them as they all have something to do with death. Anyway, osteonecrosis of the jaw is when healthy bone tissue in the jaw becomes damaged and dies (told you). Sounds nasty. Most cases happen following an extraction. Thus the appointment with the dentist. If I were likely to need to have a tooth out any time soon, I wouldn’t have the bone-hardening drug until six weeks afterwards.
Against the odds, I get an appointment with the dentist for the following day. A thorough check-up shows that while there is plenty wrong with my teeth (that’s a whole other story), I’m unlikely to need any extractions in the near future. So I go ahead and am given the zoledronic acid during my final chemo session on 25 November. It’s given as a drip over 15 minutes or so. One week on, I can confirm that it does indeed cause bone ache; this started a couple of days after treatment and it lasted for three or four days. It’s like mild stomach cramp, except it’s in your bones.
If you’re wondering how I got a dental appointment so quickly, well I did what I think is called “playing the cancer card”. I simply told the receptionist the facts and, hey presto, she said there had been a cancellation and gave me an appointment.
Also to ward off future bone loss, I’ve to take daily calcium and vitamin D3 supplements. The only times I’ve ever taken supplements were as a child (Vitamin C and cod-liver oil*) and when I was trying to get pregnant (folic acid), so this will be yet another breast cancer-enforced lifestlye change. As for letrozole, it doesn’t just put you at risk of developing osteoporosis. Bone ache and joint stiffness are other common side effects, as are “menopausal-like symptoms” such as hot flushes and night sweats. Honestly, as if one menopause in a lifetime weren’t enough.
I remember the breast surgeon saying at my very first consultation with him back in July that breast cancer “comes with baggage”. The further down the line I get with this whole thing, the more I realise just how right he was.
*Who remembers the horror of cod-liver oil capsules? Every day for years as my brothers and I left the house for school, we’d each have to take a Vitamin C tablet and a cod-liver oil capsule. My god, those capsules were disgusting! They were so hard to swallow and I can still remember the panic you felt when you realised you weren’t going to get them down your throat before the capsule coating dissolved and the oil seeped into your mouth. That memory had very rightly been deeply buried until now. I fear it may take considerable effort to re-inter it.