Monday morning (October 4, 2004) Ann had her scheduled, three-month appointment with one of her oncologists at the Kellogg Cancer Center in Evanston. This time it was Dr. Merkel, her medical oncologist, who did the examining.

The good news is that there’s no sign of cancer detected as a result of his examination. He ordered routine blood tests and indicated that recent clinical trials may result in a change in her hormone therapy from the tamoxifen, a selective estrogen receptor modulator (SERM), she is currently taking to a newly approved class of drugs called aromatase inhibitors. Whereas tamoxifen inhibits estrogen’s stimulative effect on breast tissue, aromatase inhibitors block the production of estrogen by the adrenal glands and fat cells (but not the ovaries so they are not effective for pre-menopausal women).

The Fall 2004 issue of Cure magazine has an excellent article on hormone therapies for breast cancer survivors with estrogen-receptor-positive tumors and you can read it online:

• http://curetoday.com/currentissue/features/treating/index.html

In any case, however, he won’t make the switch until August when Ann completes two years of treatment with tamoxifen.

The only bad news is that he diagnosed an infection in Ann’s forearm and prescribed cephalexin, an antibiotic, for the week. Information about this drug is available online from the National Institutes of Health (NIH):

• http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a682733.html
• http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202119.html

Ann noticed significant and persistent swelling on her wrist on Friday. Sunday she noticed pink running from her wrist arm to a little over half way up the palm-side of her forearm. Since this is the arm with lymphedema it is particularly vulnerable to infection and we were concerned. During his first year in medical school I remember my brother, Greg, telling me the four signs of infection: redness, tenderness, warmth, and inflammation. She had these symptoms (other than warmth) but the tenderness was very slight and it wasn’t clear whether the inflammation was a result of infection or lymphedema...or of the infection causing the lymphedema. Also, she’d been rubbing her arm; maybe that was the cause of the diffuse pinkness. And there was a bit of discoloration near her wrist about where the pink began that looked like a bruise. The tendons in her arm were very tight and they seemed to be the nexus of her tenderness. Given that we did a lot of work cleaning the house on Saturday and Sunday we thought that perhaps all we were seeing was an inflammatory response to a bruise and lymphedema resulting from some sort of overexertion and repetitive stress. So, rather than heading to the emergency room on a Sunday night for an immediate examination I gave her some ibuprofen and we decided to wait until morning for her scheduled doctor’s appointment.

In any case, we are a bit shaken with the discovery of an infection in Ann’s arm. Dr. Merkel pointed out a small puncture wound near where we’d only seen the “bruise” discoloration. Apparently an insect bite resulted in an infection. There seems no end to the vigilance we must keep.

If the pinkness isn’t gone on Friday we will seek additional treatment. We are monitoring her temperature—below normal at 97.9 both last night and this morning—for signs that the infection is spreading.

I contacted the physiatrist treating Ann’s lymphedema, Dr. Joseph Feldman, and he concurred with Dr. Merkel’s treatment plan. Dr. Feldman is comfortable waiting to examine Ann’s arm until her regularly scheduled appointment on November 8, just ten days before we leave for London.

This morning, after a day’s round of antibiotics, the tenderness in her arm is going away so we believe that she is not in any danger.

We hope that you are all well.

Keep in touch.

Love,

Ann and Nello

Posted by Nello at October 5, 2004 11:16 AM

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