Abstract
Case Study
A.R. is a 45-year-old woman who was diagnosed with an infiltrating ductal carcinoma of her right breast (T3N0M0; estrogen- and progesterone-receptor–positive, HER2-negative). She underwent a modified radical mastectomy followed by chemotherapy and radiation therapy. Her chemotherapy consisted of doxorubicin and cyclophosphamide every 2 weeks for 4 cycles followed by paclitaxel weekly for 12 weeks. She then went on to receive 60 Gy of radiation to the right chest wall over 33 days without significant irritation apart from the expected skin redness and itching. She was started on a daily dose of 20 mg of tamoxifen shortly after the completion of her radiation therapy. Nine months after the completion of her chemotherapy and radiation therapy, A.R. is returning for a routine follow-up appointment. Her most recent mammogram, CA 27.29, electrolyte panel, complete blood cell count, and liver function panel are all within normal limits. She reports that she is tolerating the tamoxifen well; she experiences no more than four hot flashes per week, which she does not consider troublesome. She has been able to return to work as an elementary school principal and reports that since the time of her diagnosis, she has been having problems with insomnia, depression, and fatigue. A.R. is now requesting a prescription for a sleep aid because she is not sleeping more than 4 hours at night. During her treatment she was able to nap during the day, but since returning to work, the fatigue she is experiencing is impacting her ability to do her job. She reports that the quality of her sleep is poor due to the difficulty she has both falling asleep and staying asleep. She wakes two to three times a night and is not able to get back to sleep. She is concerned that her cancer will return and feels that her job is at risk. To block out her anxiety she sleeps with the television on and has started to nap on the weekends to compensate for her lack of sleep during the week. A.R.’s current medications include the following: fluoxetine (10 mg once a day), tamoxifen (20 mg once a day), ferrous sulfate (325 mg twice a day), and calcium (500 mg twice a day).
