Monday, June 16, 2008

Welcome

Okay, Facebook has really crappy blogging apps so I've chosen to use Blogger to write my blog, but have them imported into Facebook (where all my friends are) using notes. Let's hope this goes over well. This also let's me share with friends who refuse to join the Facebook Borg.

Knowing how un-anonymous the internet is, I'll try to keep this as anonymous as possible sticking to first names only and no kids names. If someone actually reads this and comments, please follow that rule of thumb. If you are here, you probably already know me anyways.

I've never 'blogged' before, or really shared my feeling publicly for that matter. A recent change in our life circumstances has prompted me to reach out and share our journey. Why blog? I hope it will be somewhat cathartic for me. I hope that someone, somewhere who is in the same situation can benefit from my experience and maybe help me get through this journey too. I also spend a good deal of time discussing our situation individually with friends and family and so hopefully this can act as a means for friends and family to stay up to date with how Linda, the kids and I are doing.

Today marks the 6 month anniversary of our life changing event, so my next post will chronicle how we got from Dec 13 '07 to Jun 13 '08.

The Diagnosis

Christmas around our house is usually pretty chaotic. Planning usually starts around Nov 1 (Linda has been known to buy Christmas decorations in July). I have 8 huge rubbermaid tubs of 'stuff' to unload from the attic every Christmas, and every Christmas there is a new tub. Lights, reindeer, inflatable snowmen, spotlights...you get the picture. I think Linda makes up for the lack of snow in Texas by trying to cover the lawn with decorations. It is absolutely Linda's & my favorite time of the year. To be honest, we really don't need lights around the house because the glow from Linda could light the world at Christmas.

So the week of Dec 10 was shaping up to be a standard pre-Christmas week. Aside from the gifts that Santa brings, Linda races back and forth between Target, Kohls, JCPenny making sure the kids, and the pets, all have an equal amount of presents (she is really crazy that way). This week, she was finally going to get that mammogram. You see, back in September, Linda had noticed a lump in her left breast, but it would come and go. She saw her doctor who assured her that it was probably some hormone related fibroid mass. She said that when she had a chance, to go get a mammogram so they would have a baseline to measure against. Linda was 38 at the time so within a couple years she would start having yearly mammograms as the literature suggests. The visit to the lab was uneventful (if you can call having your boob squished to the size of a pancake uneventful).

Tuesday the 11th, Linda called me at the office and said her doctor saw something to be concerned about on the mammogram. They asked her to come in so they could do a biopsy on the mass. They call it a fine needle core biopsy. They stick a needle into the mass and with a little 'pop', they suck out a bit of it. They do this a couple times around the area. It is done right in the doctors office.

At this point, I was concerned, but not overly so. There is a history of these masses in Linda's family so this was just going to be one of those. She's 38 years old for Christ's sake. Linda called me after her doctor visit to see where I was on my way home from work. Turns out I was only 3 blocks or so ahead of her so I would beat her home. I met her at the door as she got out of her car and she started to cry.

I actually thought she may have hit a dog or cat on her way home and was upset about it. I really must be a moron because the 'c' word hadn't even entered my mind before this point. Not at all. This was just going to be one of those women-doctor-female-
voodoo things that some pill will take care of. It had always been that way in the past and this would be no different. Well, as you may have guessed, this was different. The surgeon who did the biopsy confided in her that, even before the results of the biopsy (which were due back on Thursday), he was pretty sure this was cancer. Fucking cancer ... and I wasn't even there for her when she first heard the 'c' word. Nice husband eh? Linda drove all the way home from the doctor's office, even called me to make sure I was okay, and never let on. It was only when she got home did she start crying...and my tears weren't far behind. This really sucked. This really, really sucked.

The next 2 days, waiting for the official biopsy, were by far the longest 2 days of my life. There had to be a mistake. I was convinced of it. This was Linda after all. She was training for a 1/2 marathon and was regularly running 10 miles on Sunday mornings. She was in the best shape that I had ever known. Eating well and exercising 5 times/week. For those 2 days, I was a mess. My eyes would well-up in my office, in my car on the way to/from work, pretty much everywhere. I prayed to God to make this better. I prayed to God to give me the cancer instead of Linda. I told God I would go to church every Sunday for the rest of my life if He made Linda better. I talked to God more in those 2 days than I have ever in my life. This may seem like a normal reaction to most people, but you see, I don't have a God. I'd done fine for 38 years without a one, but I can tell you I was looking for one desperately in those 2 days. If He was there, he wasn't listening. We got the lab results that Thursday.

I've probably been called useless several times in my life, but I don't think I've ever 'been' useless...that is until Dec 13, 2007. I'm not quite sure what the right thing to do when the love of your life, the center of your universe, your source of strength breaks down and sobs "I don't want to die". That moment is etched in my mind for eternity. I'm not sure what I said, probably something stupid like "Don't worry, we'll be fine". I do know what I thought though. "I don't want you to die either". This really, really, really sucked.

The initial clinical diagnosis. Invasive Ductal Carcinoma. 2.5cm mass in the left breast. 2-3 lymph nodes involved. Stage IIB. Moderately aggressive histological grade 7. ER-, PR+, Her2-, non-metastasized. In layman's terms, at least to me, a middle-of-the-road breast cancer. It will take some work (chemotherapy, surgery, radiation) to get rid this, but the battle is winnable. (more on the treatment in a later post)

We decided to tell the kids later that same night. I think we did it the the right way. Right for us. All huddled up on our bed, like we've done many times watching movies at night. We all cried. As much as it sucked, I will forever cherish that moment of bonding we all had.

Our journey had been set. We came to accept this was the hand we were dealt and we would get through this as a family. We still had Christmas to celebrate, it is afterall, our favorite time of year. And how did Linda cope...she planned and hosted a Christmas party for all our friends and neighbors...she is a superstar!

The Treatment (part 1)

Having spent the first 28 years of my life north of the 49th parallel, I, like many Canadians, came to believe that health care in the US was made up of pharmaceutical lobbyists, greedy insurance companies, and long lines of uninsured people being kicked out of emergency rooms because they couldn't pay...at least that's the way they portrayed it in the CBC after-school special I saw :)

Seriously though, it was a big factor for us when deciding to move to the US in the late 90s. We grew up with decent "free" health-care, so moving to a place with privatized medicine and big, bad insurance companies was something that gave us pause for thought. Our first serious experience with it came when our 1 year-old son began losing weight, vomiting 4-5 times a day and regressing in his motor skills. The doctors performed a series of tests for hearing, balance, vision etc. If the word 'cancer' doesn't make your knees drop out from under you, then the words 'brain tumor' when used in reference to your 1 year-old son surely will. All those tests turned up negative and after a few more months, we finally had a diagnosis of Celiac Disease. CD is a genetic auto-immune disease which affects as many as 1 in 122 people, most of whom go undiagnosed and spend a life of unexplained stomach/digestive problems. Because the symptoms of CD often mimic other diseases, mean time to diagnosis is 11 years. After a GI tract biopsy (the gold standard for CD diagnosis) we had our diagnosis in 4 months. The course of treatment was quite simple. Stay away from wheat, barley, rye and oats for life. Considering all the shitty hands we could have been dealt, this was an ace-high flush. 5 years later, our son is a healthy, thriving boy, and except for our references to "good-belly" (food that is gluten-free) and "boo-boo-belly" (food that contains gluten), you'd never know he has CD. I cannot say enough about the quality and timeliness of the health-care we received. From his pediatrician who initially diagnosed him to his pediatric GI specialist who treats him, we have had access to the best health-care and caring professionals the world has to offer.

We wanted to tackle Linda's breast cancer head-on, as quickly as possible, as anyone would. We were scheduled for chemo to start less than 3-weeks after her initial diagnosis. Because there was a spread to the lymph nodes, chemotherapy wasn't an option, it was a necessity. Chemo is known as a systemic therapy because it treats the whole body. Surgery and radiation are known as local therapies because they treat the affected site (her breast and lymph nodes). The only real choice we had here was the order of treatment. Surgery first, chemo second and radiation third or chemo first, then surgery followed by radiation. With the doctors help, we chose the latter because of a couple reasons.
  • There was a risk that the cancer cells had made their way past the lymph nodes and into the rest of the body. Her diagnostic scans (cat scan & bones scan) had shown the cells hadn't metastasized anywhere else but free floating cells were always a possibility. Early chemo would kill those bastards if they were out there.
  • Having chemo before surgery (known as neo-adjuvant therapy) also allows the doctors to watch the tumor and see how it responds to the drug cocktail.
With that decision made, next up was the "Power Port". Being an avid gamer, I was pretty sure this was an accessory for my XBox. Turns out it is an under-the-skin catheter that runs from the upper right chest (in Linda's case) under the collar bone and into (or near) the heart. This allows the chemo to be administered at a much quicker rate and to be diffused into the bloodstream quicker due to the proximity to the heart. A standard IV injection tends to "burn up" the veins. Nice thought eh? So just before New Years, Linda had the port "installed" at the hospital during an outpatient visit. Strangely enough they don't 'knock you out' with a proper general anesthetic, they just give you goofy gas (same stuff you get when getting your wisdom teeth out). In true Linda fashion, she managed to wake up during the surgery. Long enough to feel a burning in her chest and hear someone say "...she's awake...", then knocked back out. She has a strange knack of being in the "1%" of the "this only happens in 1% of the cases". This knack is so fine tuned that during our immigration health checkup, she actually got a mild case of German Measles from a rubella vaccine. No shit. She has her own CDC record of the event and was home-quarantined for 3 days. Some crazy odds like 1 in a million. I like to call her "patient zero".

I'm pretty sure there was some discussion about doing tequila shots in her port that New Year's Eve. We were glad to be done with 2007 and looked forward to 2008, especially Jan 2, her first cycle of chemo.

Pick Your Poison

Chemotherapy, as I see it, is an contradiction. On one hand, it is the culmination of 30+ years of intense scientific study, hundreds of thousands of hours of clinical trials and observations, harvested from obscure sources like rain-forest plant roots and a tried-and-true systemic treatment for many, many forms of cancer with millions of life-saving success stories. On the other hand, it is a poison. Designed to kill...indiscriminately.

Unlike targeted therapies such as Tamoxifen and Herceptin, which specifically attack cancer cells (or at least the mechanics common to some cancer cells), chemotherapy attacks all cells in the body. Usually injected, sometimes ingested, chemo travels to all parts of the body fed by the circulatory system and wreaks havoc wherever it goes. Although it isn't targeted to specific cells, chemo typically targets a specific cellular function or functions and jacks with it in order to cause the cell to die, whether a cancer cell or otherwise. The functions that it most commonly attacks are the cell division functions. Lo and behold, most cancer cells are dividing like crazy, that's what they do. So when the chemo is present in the body, it messes with those cells that are dividing rapidly, effectively killing them, and leaves the other cells (which aren't dividing) alone. So you may ask, isn't that targeting the cancer cell? Not really, because there are other cells in the body that are rapidly dividing too such as cells in the mouth, stomach and intestine, hair cells, nail cells etc. Guess what happens to them? Guess what the major side-effects of chemotherapy are? Wicked nausea, mouth sores, hair loss, blackened finger/toenails. Tingling in your extremities is also common because of temporary nerve damage. Throw in the inner workings of a woman's body (even in a healthy woman, that stuff is balanced precariously), hormones, hot-flashes, eye-of-newt, toe-of-frog...you can understand why Linda's first round of chemo caused some apprehension for both of us.

Chemos often work better in combination, almost like a one-two punch, or in Linda's case, a one-two-three punch. They are chosen based on the type and behavior of the cancer cells present in the tumor. Her regimen: Taxotere, Adriamycin and Cytoxin, collectively known as the TAC regimen. The drugs are administered sequentially in one sitting (takes about 5 hours in all), then repeated every 3 weeks, for 6 cycles.

On Jan 2, we showed up at Texas Oncology ready for the unknown. If you know Linda at all, you know she plans everything to the nth degree. Lists upon lists of things, plans, backup plans, alternates to the backup plans. There is no doubt we could have camped out in the infusion room for a few days with everything Linda brought with her that day. Every imaginable scenario had to be covered. Flood, drought, famine etc. Blankets (both thick and thin), shoes, slippers, sweaters, 2 ipods (one for me, one for her), sandwiches, fruits, vegetables, cold drinks, hot chocolate, books, the latest grocery checkout line finds of People, US, Ok, Star and others (sorry, those are my secret guilty pleasure), a newly acquired day planner of dates/times/schedules/metric conversion charts...oh and yes, a duck.

The duck is an inside joke between her and her girlfriends, who now call themselves her 'breast friends'. At some point in time, it resided in a lakehouse the girls rented for a weekend getaway. But now, over the past year, the duck has been found randomly by one of the girls in their kitchen pantry, bathroom, freezer, tree or other surprise location.

So Linda, facing the greatest uncertainty of her life, still lit up the room with her trademark smile and brought along a duck for a little comic relief in as much to say "Don't worry guys, I'll be fine". If that is not courage, I don't know what is.

The Treatment (part 2)

The 'infusion room' sits on the top floor of Texas Oncology's brand new building near the center of the city. You park underneath and take the stairs or elevator to the 2nd floor. Linda always chose to use the stairs. To her, it became a benchmark to see how badly the chemo was kicking her ass over the next 4 months. To me, it was just a reminder of how out-of-shape I was. Emerging from the stairwell, you are presented with a large, nicely decorated reception area. To the right, administrative booths and further down the hall, exams rooms. To the left, scheduling booths, a pharmacy and further down, the 'infusion room'.

Unlike what I had expected, it is not a depressing place...and I don't mean the decor or lighting, I mean the people. You'll find people there from every walk of life, and every age: Big burly guys, little old ladies, a young lady listening to her ipod, someone watching Jerry Springer, and a 39 year old woman fighting breast cancer. I think by the time people get to the actual chemotherapy, they are past the initial cancer shock and are anxious to get going with their treatment. Now don't get me wrong, no one wants to be there, but if life's journey sends you down this path, this place seemed to be, at least to me, a place of hope and not despair.

Prior to any treatment, we always saw the oncologist (the cancer doctor). Linda managed to get one of the best oncologists in the city. Although very clinical, Dr. H. has an incredible ability to reassure you. She would always explain what our options were and what we could expect. She directed treatment but never dictated it. She has just the right balance of professionalism and compassion. Blood-work was also a staple of every visit. They had to make sure Linda was healthy enough to poison.

The infusion room has 4 sections. Each section is separated by a half wall. Each section has 8 chairs, with 4 chairs that face the other 4 chairs. It has big windows on 3 of the 4 walls making the room nice and bright. For every 2 chairs, there is 1 overhead TV (above the heads of the chairs that face you). Aside from eradicating the cancer from her body, the primary goal of every visit was to secure access to the remote control for the duration of her stay. There was no way that Linda would allow someone else to control her TV viewing destiny. As you can see in yesterday's photo, even before starting any chemo on her first visit, Linda had already seized control of the remote.

For all the build up, the anxiety about the treatment, the unknown, the first infusion went very well. They hooked up bag #1 (which I think was the C) and it dripped away for a couple hours. Linda really didn't notice anything at all. #2 was the A. This is a bright red liquid that is manually injected into the port by the infusion nurse. Adriamycin has the potential to be very bad for your heart, so they inject it slowly by hand to watch your reaction. The nurse sits there with a big ass syringe and slowly, for 20 mins, injects the red chemo. They call it dessert. If they pump it in too fast, you may get a headache, but that's usually it. After the A was the T. It too dripped away uneventfully for a couple hours. I don't know what I expected, but it wasn't that. I think I asked Linda "how do you feel?" every 10 minutes or so for our entire stay.

Armed with a day-planner-full of anti-nausea prescriptions, we drove home and sat outside that evening as we usually do during school breaks (it was still Christmas break for the kids). The neighbors came by one by one to see us, almost incredulous to the fact that Linda was outside. I doubt the words were actually spoken, but I know Linda and I for a moment thought the same thing..."this chemo stuff is easy"...ohhhh shit!

The Fallout

New advances in cancer research are not only confined to the prevention, detection and treatment of cancer, but also include huge changes in the world of anti-nausea drugs. Next to the cancer-fighting capabilities, the next thing most people think about when they hear chemotherapy is the debilitating nausea. I know we sure did. As little as 10 years ago, that may have been true but 'big pharmaceutical' has made huge strides in that area. In 99% of the cases, nausea has become a non-event in chemo treatment. Sure there are many other side-effects to chemo to keep you occupied like extreme tiredness, nerve damage, hair loss etc but the nausea, in 99% of the cases, is non-existent.

You may recall how the 1% rule applies to Linda. Man, did she get sick after that first round. The slide from "I don't feel a thing" to "I'm getting sorta crampy" to "Get me the barf bowl" only took about 2 hours. It was full-on. It was so intense that Linda ended up back in the infusion room the next morning to get re-hydrated via IV...and again the next day. Even though Linda was on Kytril, Decadron and Phenergen, three very good anti-nausea meds, the doctors had grossly underestimated the Linda 1% factor. This is the same woman who gets sick reading in a car, sitting sideways on a bus, watching me play a video game and nearly vomits on the 'Barnstormer' kiddie ride at Disneyworld.

After 3 days, Linda started to recover from the chemo as it left her the body. The nausea subsided and Linda was coming around again. I can't really explain what she went through, only she could, but in the big picture, it was worth it. For those 3 days I busied myself doing all the laundry (I was pre-instructed on how not to mix whites & colors), cleaning the house (Honey, the dishes go this way in the dish washer, not that way), corralling the kids, and checking in on Linda every 5 mins. I know I couldn't 'fix' her pain, but I sure as hell could make it easier for her. It's pretty much a blur, kinda like when you bring a newborn home from the hospital for the first time. On the plus side, 'the unknown' was behind us now. The doctors took out the 'big guns' for the next round. Emend, Aloxi, and Ativan and they would prove to be a huge difference, but before we could get to Round 2 we had to face the inevitable: Hair Loss.

Chemotherapy doesn't actually kill the hair follicle (which is why the hair loss is only temporary), it just messes with the hair cells when they are dividing at the root under the skin. Those new hair cells are extremely fragile, so in 2 weeks, when the hair grows up past the skin, it simply snaps off.

Many women choose to shave their heads as an act of empowerment over the cancer. Earlier that year we had watched Robin Roberts of 'Good Morning America', recently diagnosed with breast cancer, shave her head on TV. Little did we know we would be faced with the same situation only months later. For Linda and I, it was a practical matter. There was hair everywhere. On the pillow, in the shower, on the couch. You could literally pull out a chunk of hair just by clutching it. I've known Linda for 16 years and in that time, she has never liked her hair. Too thick, too thin, too curly, too straight, too light, too dark, too gray, too short, too long. As fate would have it, in the months leading up to this, she was finally happy with her hair. Go figure!

Even though it was a practical matter, it was still quite emotional. Linda's friends had suggested she have a hair-cutting party with wine & cheese. It was too personal a thing for her to do that. This was our battle. The four of us, as a family, armed with the Wahl buzz cut kit I has bought earlier that day at Target, began to shave off her hair. The kids took their turn as we worked our way down from a #3 to a #1/2. After 15 minutes we were done. It is the not the physical act of shaving your wife's head that is emotional, it is the realization that you can no longer deny the fact that your wife has cancer. Every morning, we would be reminded of our fight. After a while I think we got used to it, if that is possible. Linda's friends threw her a hat and scarf party. Everything from "pretty hats" to "skull and cross-bone do-rags". Not only did it allow her to cover her head, but it gave her more reasons to buy more purses to accessorize with (someday I should write about Linda's purse 'issues').

This is kind of an aside, but Linda's bald head turned me on. No, not in a gay-Telly-Savalas kinda way. You really can't get much closer mentally, spiritually and physically than shaving your wife's head in the shower.

In public, like it or not, a bald head on a women is like a neon-light saying "I have cancer". You get the strangest reactions from people. Honestly, most people are too busy with whatever they are doing to even notice. Some people will be extra nice and a bit sympathetic. Some people just stare like there is a neon-light on your head saying "I have cancer". One evening we took the kids to Gattiland, an all you can eat pizza place with arcade. As we were eating, a couple sat down next to us and began to eat. He looked over at Linda, whispered something to his wife, she looked over, then they got up and changed seats. Are you fucking kidding me? Hey jackass, you can't catch cancer! For one moment, I wished cancer was contagious because I would have had Linda get up and give that bastard a bear-hug.

In support of Linda's follicly challenged head, some of her girlfriends joined the Sinead O'Connor tribute for a day. Many people wonder what they would look like bald. My genetics predisposed me to some cro-magnon-like appendage on the back of my skull that I like to refer to as the "bottle-opener". Turns out Linda has a very nice melon. Smooth and round. A childhood accident has carved an "L" scar on the back of her head which was hidden for 30+ years. It will soon be covered again with wavy brown hair but for now it serves as a nice monogram.

The Grind

...and so went our lives for the next 4 months. TAC chemotherapy every 3 weeks for 6 cycles. As is much possible, it almost became routine. With the new anti-nausea meds, the poisonings became bearable.

Wednesday was a visit with Dr H. and chemo day. A quick blood test would make sure Linda was well enough to receive her treatment. I'd leave her in the chair with her blanket and remote control and head off to work. I'd pick her up again around 3pm. One of our friends would make sure the kids got off the bus ok and take care of them until we got home. With no immediate family in town, we really came to appreciate the good will of our friends and neighbors who all wanted to help in whatever capacity. Knowing she'd be out of commission for a few days, Linda would try to finish her chores as it usually took a few hours before the 'blahs' kicked in. By 7pm it was time to tuck her and the kids in for the night.

Anyone who knows me knows that I am not a morning person. My biggest adjustment to the new routine was getting up at 6am to get the kids ready for school and putting them on the bus on Thursday mornings. I never knew people were actually up and about that early in the morning. Who would of thought? Hell if Linda could endure 4 months of chemo, I could surely endure 1 morning every 3 weeks right? They don't just sell those 'Super Dad' coffee cups, you have to earn them! On the agenda for Thursdays was as a quick visit to get a Neulasta shot. Neulasta helps the body create more white blood cells.

By Friday, Linda would usually be feeling better, enough so to get the kids ready for school and bring me my cup of coffee in bed in the morning (did I say that I love her?). We normally took the first weekend after chemo pretty easy. The other 2 weekends of the cycle were the standard 'how do we entertain our kids?' weekends of movies, camping and such. Linda actually had her chemo (and recovery) scheduled around the weekends to make sure the kids and I were impacted as little as possible.

By midweek the following week, Linda would go in to check her "levels". Chemo affects both blood cell types. The red blood cells carry oxygen around the body and when they are low, you feel tired and sluggish. White blood cells fight off infections. Both of theses cells end up being depleted during chemotherapy. About a week after treatment is when you are at the bottom of your cell roller-coaster and although you feel great (relatively speaking of course), your body is very prone to infection. Linda would avoid going to public places during this time and carry a little bottle of hand sanitizer with her.

Compared to round1, rounds 2 and 3 were a cake walk. After the first round, the tumor in Linda's breast and lymphs nodes began to break up and started to feel mushy. After the second round, the tumor was almost non palpable in her breast and nodes. After round 3, you could no longer feel the tumor at all. Just a small crescent shaped bump of scar tissue from the original biopsy. The nature of Linda's tumor made it extremely sensitive to this regimen of chemotherapy. The choice of pre-surgery chemo also began to show its merit as we could see that the TAC was doing its job effectively.

Chemotherapy has a progressive, cumulative effect on the body. You never bounce back to where you were before the round. Although the nausea effects are the same for each round (now under control), the tiredness builds and builds. By the time Linda had 4 rounds, in mid March, the chemo was taking its toll both physically and psychologically. She stayed in bed for 4 days straight after the 4th infusion. She couldn't even stand. She collapsed in tears one day on the bed saying "I can't take this shit anymore". She is a very strong woman but had finally came to accept that this chemo was kicking her ass. Although the physical strain had taken its toll, I believe at this point it was the psychological aspect which really affected her. Her friends, with whom she trained for the marathon, were now running the marathon. Friends were basically continuing on with their lives and she really felt left behind. It was really tough on her. I guess before you come up, you must go down and I think this was the bottom. As a typical guy, I tried explaining logically why she was feeling this way and that, in fact, no one had abandoned her and everyone was still there for her. Well 'logic' and 'woman' go together like oil and water. I think when I simply acknowledged that she had every right to feel this way did she start to feel better. The fact is no one can be upbeat all the time. My 'bottom' would come a couple months later when, after Linda's treatment, I started to acknowledge what a toll this was taking on me.

But before I get into that, Linda was starting to feel better and we could see the light at the end of the tunnel. Linda needed some shopping therapy...and not just any shopping...cranial prosthesis shopping!

The New Do

Somewhere down in clause 2.2.3, subsection 2a of our medical insurance, under "Durable Medical Equipment", you'll find an entry for a Cranial Prosthesis. Do they really have to call it that? If it just said "Wig", wouldn't every English speaking human understand what it meant. The insurance company website has green fields with trees, patients (sorry...members) laughing, doctors in white jackets and some tag-line about caring, compassion, health...blah, blah, blah. I don't know, it just seems kind of hypocritical to me to talk about all that big corporate compassion shit, and still, they expect you to feel good about getting pre-approval for a "cranial prosthesis" for your wife. Just call it a wig! That way, I can go to the pamphlet (that I had never read up till this point) and go to the index of "Shit I'm covered for", under W, and see Wig = "Up to $500". That'd be so much easier.

Don't get me wrong, our insurance has been fantastic (fingers crossed) and nothing in Linda's treatment has been denied (fingers crossed) and we get to go see who we want, when we want. Still, the word "Cranial Prosthesis" in subsection 2a, under "Durable Medical Equipment" in clause 2.2.3 made me realize that we are just a number in some vast private health-care system and, aside from our team of oncology doctors who really do care about us (more specifically Linda), we are a series of claims and "explanation of benefits" forms to the industry. One of my biggest fears is that someday the insurance company computer will flag us as 'non-profitable' (which I'm sure we already are...I've seen how much this treatment costs) and we will be denied. That day hasn't come, but if it does, we've always got that passport with the Queen and Maple Leaf on it as a safety net.

From the day Linda first lost her hair, the option of a wig was always on the table but it took her 3 months of do-rags before she finally decided she wanted one. I think she just got fed up with all the awkward staring. So with a prescription in hand and a girlfriend by her side, off they went to the wig shop. As a side note, it was a good idea to take a woman along for advice. Don't ever ask a guy if something looks good as he is programmed to always say 'yes', even if it looks like a group of sparrows nesting on your head.

Linda would kill me if I posted some of the photos of the hair she tried on that day. The fact that she thought it'd be funny to have us draw all over her head before she went to the shop is phenomenal. In true Linda form, she thought of the kids and I first and turned what was probably a difficult thing for her into a fun activity for everyone else. (btw I Photoshopped my kid's names out of the photo).

Linda got her wig and wore it for a couple of weeks. She donned the do for a few 'occasions' where a do-rag wasn't quite appropriate. You must realize that in April and May, the temperatures in Texas are already in the low 90s so having a nylon/polyester wig on your head isn't all that comfortable. Also, the hairstyle wasn't quite the same as her own, so Linda never felt comfortable wearing it. In the end, Linda was more comfortable in her do-rag and preferred the awkward looks of 'that lady has cancer' over the awkward looks of 'that lady has really bad hair'.

The Bell

As you enter the infusion room, there is a small brass bell on the wall to your right. Everyday someone rings that bell. The room is normally pretty quiet so a clanging bell easily gets your attention. That attention is well deserved. Every single person who rings that bell has had their own "Dec 13", a life changing day where a doctor told them they have cancer. Every single person who rings that bell has endured the painful side-effects of some cancer related treatment. Every single person who rings that bells hopes it is the last time they see that bell.

Linda may have missed out on the half marathon she was training for, but on April 16th, she finished the first part of her triathlon. It was her time to ring that bell.


(click 'View original post' if video doesn't display)

Like the big suck that I am, I got pretty choked up that day. Truth be told, I tear up during the ASPCA dog abuse fund-raising ads on TV so tears on my cheek are no monumental event, but this was big. For a small moment, we could declare victory. There are no guarantees in this fight, and Linda still had surgery and radiation therapy to go, but this felt good and sounded sweet.

You can hear Linda at the end of the video clip saying "We did it". From holding her hand for comfort during the first infusion to not mixing whites and colors in the laundry to proudly watching her ring that bell, we did this as a team (even though I was literally the 'water boy ' through most of it). We are stronger because of it and every day I am thankful to have Linda by my side.

With the help of friends and neighbors, we threw Linda a surprise post-chemo party. Friends, kids, presents, cake, and balloons (everything pink of course) were waiting for her when we got home that day. She finally cried.

New girls?

Months before Linda was diagnosed, one of her good friends was also diagnosed with breast cancer. Linda's reaction at that time was "If I ever get breast cancer, I'd have them both removed, no question about it". She couldn't understand why there was even a question in her friend's mind. Why would she take the chance of it coming back?

A complete mastectomy has pretty much been the de facto outcome for breast cancer over the past 50 years. Today, there are many options in breast conservation treatment (lumpectomy) as well as re-constructive surgery after a mastectomy. There are some cases where a modified mastectomy (either one or both breasts removed) is recommended. In particular, during genetic testing, if the BRCA1 or BRCA2 gene mutation is detected (the "breast cancer gene"), then the odds of re-occurence are significantly higher and a complete mastectomy (and hysterectomy) is often the chosen course of treatment. If the tumor is large or the surgeon is unable to get "clear margins" during a lumpectomy, then the entire breast may also be removed. Clear margins simply means that when the surgeon removes the tumor during a lumpectomy, a biopsy on the mass is performed to ensure that there is a clean margin around the tumor free of disease, meaning that the tumor hasn't spread outside the margins. Another reason for a complete mastectomy is the peace of mind it may bring. Insurance will typically cover all the costs associated with breast reconstruction, or as Linda referred to it, "getting some new girls".

After several weeks, Linda had recovered enough from her last chemo, and the lumpectomy vs. mastectomy decision we had talked about 100 times was finally before us. Modern research has shown that, outside the special cases above, the long term survival odds for lumpectomy vs. mastectomy are the same and the odds for reoccurence are only slightly higher for lumpectomy vs. mastectomy. According to Dr H., since the stats are about 10 years old, before BRCA testing, 20% of those lumpectomies were probably performed on BRCA+ women and therefore the reoccurrence odds are likely skewed. If you factor that in, as well as cases where clear margins weren't achieved and cases where the woman chose not to follow up with radiation treatment, the odds for reoccurence are probably about the same.

Linda's BRCA testing came back negative, which was a huge relief, not only for Linda but also for our daughter (she wasn't aware of the test implications but luckily we can tell her the good news when it is appropriate). Even so, Linda was still contemplating a complete bilateral mastectomy at this point. It wasn't until we were told that Linda would need to wait about 1 year for breast reconstruction that she decided for a lumpectomy. You see, her follow-up radiation would end up damaging any implants that were put in during the mastectomy (something were weren't made aware of until Linda talked with her radio oncologist). So they would need to do the mastectomy, then the radiation, then let the area heal, then do the reconstruction. After everything she'd been through up until this point, and pretty much even odds, the thought of 1 year without breasts is not something Linda was willing to face.

I like boobs just like the next guy, maybe even more, but not for one second did I ever consider that to be a factor in our decision. I'd be lying if I said I didn't think about it. Of course I did. I think about boobs maybe 25-35 times a day, and sometimes they are my wife's :) Seriously, I wanted her to be healthy and happy about her decision whatever it was. As it turned out, we decided against the "new rack" and opted for the less invasive lumpectomy. The boobs I met when they were 24 were now 39 and would be coming home from the surgery which was now scheduled for May 23.

Surgery

Prior to the lumpectomy, Linda's surgeon Dr. N, ran her through a bunch of imaging tests to plan the operation. She had another mammogram, a PEM (positron emission mammography) and a MRI (magnetic resonance imaging). To the best of my understanding, mammograms and MRIs are visual diagnostic tools whereas the PEM, basically a breast only PET scan, is a biological diagnostic tool. For the PEM scan, you swallow a radioactive isotope (something that emits positrons I assume) in a glucose solution. Cancer cells like to eat sugar, more so than other cells, and therefore after waiting for the glucose/isotope to make its rounds of the body, a PEM scan will "light up" those areas with a concentration of the isotope, likely cancer cells.

Linda's tests showed there was still some traces of cancer in her breast and lymph nodes after her 6 rounds of chemo. We were hoping for what they call a pCR (pathologic complete response) but instead we got a very good partial response. Even with a pCR, you still typically follow it up with a lumpectomy and radiation so the lack of a pCR didn't immediately affect the course of treatment. From the test results, the surgeon knew where and how much to cut.

The surgeon had us scheduled for surgery the morning of May 23rd at St. David's Medical Center. She never asked us if we were Catholic. Should you be Catholic if you go to a St. Something hospital? I don't think we had a choice and I never asked, however I was pleasantly surprised to find out that I didn't burst into flames when entering the hospital that day. Must of been Linda's Christian upbringing that saved us. After the requisite form filling and sign-in procedures, we made our way to the pre-op room. Linda got into her 'gown' while I found something decent to watch on the TV. Over the next hour, several doctors, nurses and orderlies made their way into the room. Each one of them looked at Linda's chart, flipped through some other paperwork, asked Linda her name and date of birth, checked something off their list, double checked her arm bracelet and continued to do whatever it was they were there to do. There must be enough 'guy goes in for a vasectomy, guy comes out without a kidney' stories to warrant all this behavior, but better safe than sorry I suppose.

As one of the orderlies went about his business, he made a remark to Linda about 'making a fashion statement'. We assumed he was talking about Linda's do-rag that she was still wearing. Linda got a bit miffed about the comment. "What the hell was that comment about? Doesn't he know I have cancer? That was kind of inappropriate". She stewed in her anger for about 15 minutes until a nurse came in and said "Honey...you have your gown on backwards...you might want to turn that around". Only then did we realize what the orderly was taking about. Holy shit we laughed...to the point of tears. All our pent up anxiety came out and I'm sure they could hear us down the hall. It was friggin' hilarious and fantastic. Before long, they came and got Linda and wheeled her into the OR.


The 3 hour surgery had 2 stages.

1. Remove what remained of the tumor in her breast
2. Remove any cancerous lymph nodes

The first part was pretty straight forward. Cut out the tumor and enough of a clear margin to make sure you get it all. The lymph node surgery is a bit more complicated. Up until fairly recently, lymph node removal involved what they call an 'axillary dissection'. They basically would go in and remove an entire level (maybe 2 levels) of nodes (there are 3 levels in all) in the hopes they got any cancerous nodes. A 'sentinel node biopsy' is a new technique where they inject a blue dye at the tumor site and see which lymph node the tumor drains to. The first one it hits is called the 'sentinel node'. This is likely the first node you'd find cancer in if it has spread (which we knew it had but were unsure of its state after chemo). They take that node and, during the operation, slice it in half and run a 'touch test' on it. I'm not quite sure what the touch test involves but it determines if there is cancer in the node. If cancer is found, then they go the next one in the chain. If it is found to be cancerous also, then they continue on and take out a chain of them. If no cancer is found in the sentinel node, then they are done and do not take out any more. Why don't you just take them all out and make sure all the cancer is gone? Lymph nodes are an essential part of the body's defense system. All parts of the body drain to lymph nodes (some under your arm, in your throat, in your abdomen etc). If you mess with those areas too much, you risk getting a chronic condition called lymphedema. If you've ever seen someone with a full length compression sleeve on their arm, there is a good chance they have lymphedema.

The only other time I had been in a waiting room was when my son had his Celiac disease biopsy, and Linda was there with me. Now I was alone with only my thoughts. During those 3 hours I must of walked a good 20 miles up and down the halls. At one point I sat down to watch CNN which was on the TV in the waiting room. I was terrorized by some 2 year-old who was making his way around the waiting room. His grandmother would call him back every 5 minutes or so for a refill of juice and Oreos. He fell somewhere between cute and objectionable. It was only after he tried to grab my vending machine dispensed honey glazed donut for the fifth time did I realize he was waiting for his mother to come out of surgery...and grandma was waiting for her daughter. All of a sudden he didn't seem quite as aggravating. I offered him some of my donut but he was no longer interested. Little bastard.

2 hours elapsed and I hadn't heard anything. The dude (by dude, I mean a 20-something guy who was way cooler than me) at the front desk approached me, "Are you John? Dr. N would like to talk to you on the phone". What the hell? A doctor calling me? Is this good or bad? It was in between. Dr. N informed me that the lumpectomy had gone fine and she was confident she was able to get clear margins however the sentinel lymph node tested positive for cancer metastasis as did the second one. Fuck me. I had "paid it forward" with the donut offering and this is the thanks I get. This sucked ass. Dr N. went in and removed 17 more nodes, the pathology of which we wouldn't know for a week. It would be another hour before Linda was out of surgery so I took a walk outside in the 100F Texas heat.

I walked around the block which was under construction, near some shitty student housing and right next to the busiest freeway in the US. Not quite the relaxing walk I needed. As I walked down the frontage road to I-35 I passed an Ethiopian restaurant. It looked like it had gone belly up. No kidding? Nothing says home cooking like bowl of porridge with flies on it. Needless to say I ended up in the hospital cafeteria. I sat there for half an hour eating my sandwich and people watching. I watched a guy come through the checkout line. He had nasty burn scars on every piece of skin I could see. He chatted up the checkout girl like he knew her and had obviously been in this cafeteria many times before. For all the shitty luck we'd had over the past 5 months, I guess "sucking ass" is a relative term.

As I stepped off the elevator into the waiting room, the dude at the front desk informed me my wife was in recovery and I could go see her at any time. I actually said 'Sweet' to him in a pathetic attempt to be as cool as he was. I think I missed it by a decade or more.

After she woke up, we laughed some more about the backward gown. I loaded my semi-drugged-up Honey into the car and brought her home.

Post Op

Linda healed quite nicely from the surgery. Dr. N did a fantastic job and the only visible indication of the lumpectomy and axillary dissection are a couple very fine 2" scars. They will heal up nicely over time. The neo-adjuvant therapy (pre-surgery chemotherapy) had shrunk the tumor down to nothing and that, combined with Linda's already "ample" boobs made for a truly unnoticeable lumpectomy. Dr N ended up removing an extra 17 lymph nodes in addition to the 2 sentinel nodes for a total of 19.

A detailed pathology of the tumor and nodes was performed off-site and we had the results within a few days. The lumpectomy did indeed achieve clears margins which was great news and as suspected, the lymph nodes tested positive for cancer. The first 2 sentinel nodes still had visible clusters of cells but the next 3 in the chain had diminishing amounts of micrometasteses. Basically, there were cancer cells in those 3 nodes but they hadn't set up shop yet. The rest of the 14 in the chain tested clear for cancer. Also of note is that all the nodes tested negative for ECE (extra capsular extension) which means the cancer cells hadn't broken outside the walls of the nodes...a good prognostic indicator. As important as anything, it was also a great psychological relief for Linda and I to know that the cancer we first saw on Dec 10th was finally out of her body. Linda began to do her exercises to prepare for radiation treatment. She needed to be able to lift her arm over her head which is no easy task after someone has been digging around with a scalpel in your underarm. It'd take about 3 to 4 weeks.

Her recovery was moving along so well that yours truly finally got lucky. If you think "make up" sex is good, it ain't got nothing on "we just got through the toughest thing we've ever had to face" sex and "no action for 6 months" sex. Don't get me wrong, I was a 15 year-old boy once so I could rub one out like a pro, but after 6 months that gets kind of old and you find yourself getting creative. Have you ever heard of The Stranger? Seriously though, I know Linda will kill me for this paragraph but it did feel good to be a normal couple again. That's all I have to say about that.




i feel like i can fly when I stand next to you

I made this video for Linda to cheer her up when she was feeling her worst.



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There's something that I can't quite explain
I'm so in love with you
You'll never take that away
And if I've said it a hundred times before
Expect a thousand more
You'll never take that away

Well expect me to be
Calling you to see
If you're OK when I'm not around
Asking "if you love me"
I love the way you make it sound
Calling you to see
Do I try too hard to make you smile?
To make us smile

I will keep calling you to see
If you're sleeping, are you dreaming
If you're dreaming, are you dreaming of me
I can't believe you actually picked me

I thought that the world had lost it's sway
It's so hard sometimes
Then I fell in love with you
Then came you
And you took that away
It's not so difficult
The world is not so difficult
You take away the old
Show me the new
And I feel like I can fly when I stand next to you
So while I'm on this phone
A hundred miles from home
I'll take the words you gave me and send them back to you

I only want to see
If you're OK when I'm not around
Asking "if you love me"
I love the way you make it sound
Calling you to see
Do I try too hard to make you smile?
To make us smile

I will keep calling you to see
If you're sleeping, are you dreaming
If you're dreaming, are you dreaming of me
I can't believe you actually picked me

Blue October - Calling You

Are we done yet?

So there we were, preparing for the third leg of the triathlon, radiation therapy. Linda had already met her radio oncologist a few times before and this Friday she had an appointment to get marked up so they could target the right areas. Left breast and underarm. They can get pretty precise in their targeting but not perfect. The choices were lose 10% of left lung capacity or 10% of the heart. I don't think it was actually a choice. With Linda's lungs able to take her on a 13 mile run, a 10% loss would not even be noticeable.

Linda called me at the office saying the first radiation treatment was being postponed. When I asked her why, she said the radiation doc informed her that Dr. H wanted to do more chemo. I immediately felt that deep ache in my stomach all over again. What the hell was going on? Linda has a tendency to not ask questions of her doctor (which is one reason why I attend all her appointments with her...except this one of course). This was a Friday afternoon and I went into full panic mode. I must of called Texas Oncology 5 times trying to get through to Dr H. without any luck. I left message after message with her nurse and receptionist. Linda had a scattering of details from the radiation oncologist about what the new chemo cocktail would be, but she "misremembered" the names. I spent Friday night chasing down the drug names on the internet to hopefully gain some insight into why she was getting more chemo. With the drug names being wrong, it took me to places discussing distant metastases, liver cancer and other shit that just made the knot in my stomach tighter. I try to discourage Linda from getting on the net and googling stuff because she invariably finds some story or statistic that makes her sad and depressed. I've tried to explain to her that she is a unique case and all the stats in the world mean nothing and all the stories have no bearing on her ultimate recovery. Of course she ignores me anyways, reads the stats and the stories and gets depressed...and then I do.

The thing that sucked is that Linda and I started running again. No, not 13 miles yet, but 1 mile. An incredibly difficult mile for her but one that felt great. At this point, she almost had full range of motion of her arm and her peach fuzz hair was just starting to grow back. After 6 months of crap, things were finally starting to look up.

Maybe we were too eager to 'be done' with this and put it behind us. Maybe we just wanted our old life back, a life not dictated by tri-weekly poisonings with 'up weeks' and 'down weeks'. Maybe I should have gone to church after all. Whatever it was, it would be a long 48 hours before we would learn why Dr H. wanted to continue chemotherapy.

More chemo

Current non-surgical treatments for breast cancer can be broken into 3 categories (at least I see them as 3 different categories). Systemic chemotherapy, endocrine (hormonal) therapy and targeted therapy.

Systemic therapy is the classic chemotherapy you probably know and is what Linda went through for 6 cycles of TAC. Current research in this area is trying to discover which cancers cells are more susceptible to which kind of chemotherapy. Not all cancer cells are alike and certain markers in the cell can help determine which drug cocktail works best, if at all. Because chemotherapy is the most disruptive of the treatments to the rest of the body, it makes sense to only follow a regimen, if any, that has the best odds of success.

Endocrine, or hormonal therapy takes advantage of certain receptors on the cancer cell. Some cancer cells 'feed' on estrogen and progesterone. Cells that behave in this way are known as ER+ and PR+. Tamoxifen is a drug taken daily in pill form, usually for up to 5 years after initial therapy. To the cancer cell, it looks a lot like estrogen. The estrogen receptors on the cancer cell get blocked up by this 'low powered' artificial estrogen hormone. Because the receptors are blocked by this fake, the cell can't feed on real estrogen and the cancer cell ultimately dies. Although Tamoxifen and similar drugs have side effects generally related to a women's internal chemistry (bone loss, hot flashes etc), the side effects are not nearly as life disrupting as chemotherapy and can therefore be taken for a long-term insurance policy against the cancer coming back. About 75% of breast cancers are ER+/PR+.

Targeted therapies are where the huge advancements in cancer drugs are currently being made. As little as 10 years ago, a woman who was Her2+ had a significantly worse prognosis than one who was Her2-. These types of cancer cells, which have an amplification of the Her2 gen, are typically resistant to both chemo and hormonal therapies. There wasn't really a treatment option for them. Today however, thanks to our understanding of the human genome, Herceptin is a drug that was developed to specifically target the Her2 gene (I won't pretend to know exactly how it works, but you can Google it and see what a change it has made in breast cancer treatment). About 20% of breast cancers are Her2+. Leading edge research is discovering other genetic 'defects' in cells that can be exploited to kill off the cell or halt cell growth. Understanding how cancer cells acquire oxygen and cutting off their supply (anti-angiogenesis) is at the forefront of cancer research today.

Understanding the nature of Linda's cancer cell is important to understanding the treatment options. The initial biopsy of the tumor indicated that Linda was ER-,PR+ (15%), and Her2-. A pretty rare combination (remember the Linda 1% factor). This meant that Tamoxifen would have limited effectiveness in long term treatment and Herceptin was not a viable treatment option either. Systemic chemotherapy was our only tool to fight this cancer. As fate would have it, cancer cells like these are very susceptible to chemotherapy which is why we noticed an incredible attack on the tumor in her breast. With such great results, why then did Linda require more chemo? Remember those 2+3 positive lymph nodes? Dr H. said that if the cells in the nodes were the same as those in the breast, she would have expected them to be destroyed too, but they weren't. After further analysis of the pathology, it turns out the cells that were left in the lymph nodes were a bit different than those in her breast. They were ER+ (faint), PR-, Her2-. Did they mutate because of the chemo? Were they different to begin with? It was unclear. Now understand that those nodes were removed during surgery, but there was still a chance that cells of that type had escaped into the bloodstream. Without Tamoxifen or Herceptin as a backup plan, and to increase our odds, we decided that another round of chemo was the right thing to do. There was a good chance that with the original chemo, the lumpectomy and node removal, the cancer had already been eradicated from her body, but if a secondary chemo treatment could push the odds in our favor, even just a bit, then it was a worthwhile thing to do.

I talk like 'we' had a choice, where in reality it was Linda's decision. I am in awe of her resilience and strength, not only to fight for herself, but if you know her, you know she is fighting for our entire family. She fights so that I have a wife and that our kids have a Mom. For that, I am eternally grateful and love her unconditionally.

Can you pass the cisplatin and etoposide please?

I am finding I do most of my blog updates when Linda is in active treatment, and this week has proven to be no different. I sit here typing this on 08/08/08 and have pretty much got caught up on current events. Although I think about our cancer all the time, during down weeks when Linda gets her infusion(s), I think about it every second of every day. I guess writing about it helps take some of the edge off, but it still eats at me. Has it been therapeutic? Somewhat, yes. I can write paragraph after paragraph on how fantastic Linda is, because it is easy, she is incredible. When I write about her, I don't have to deal with my own shit. Someday, maybe, I'll write my 'woe is me' post about the fears, guilt, sadness, anger, and the 'this sucks' feelings that are apparently common to co-surviving husbands, but for now let's stick with the easy stuff.

This week, Linda finished her 3rd cycle of cisplatin+etoposide (EP) chemotherapy. The EP regimen is not typical for breast cancers and is usually part of lung or testicular cancer treatment. Recent studies have shown that platinum based therapies have made a significant increase in the 10-year disease free survival statistics for cancers similar to Linda's. The regimen consists of 4 cycles each separated by 3 weeks (last time it was 6 cycles separated by 3 weeks). This time however, instead of 1 day of chemo per cycle with TAC, EP gives you 3 days in a row per cycle. Day 1 is cisplatin+etoposide, day 2 is etoposide only as is day 3. A shorter overall time-frame as compared to TAC therapy, but twice as many infusions.

Linda tolerates EP pretty well. The first cycle was the big unknown. Side effects are similar to TAC and yes, this usually includes hair-loss. For a while, we thought the Linda 1% factor would leave Linda with her new hair, but there is no doubt now that it'll all go...again :(. I think the lows are a bit lower than TAC but the intermediate recovery seems to be a bit quicker. Because of Linda's nausea issues with TAC, she over-prescribed herself with Decadron on her first round of EP. It is a steroid and she became wired from it, unable to sleep and heard voices. She toned it down for #2 and #3 and they were much better...less crazy!

In 3 weeks we'll be done chemo. Linda says she is ripping the bell off the wall this time. I may give her a hand. Unfortunately, her last cycle falls on the first day of school, usually a big production around our house. Just another fucking reminder that our lives will never be the same. (wow, I just re-read that last paragraph and I think I'm in a funk, probably just my 'male period' moodiness I seem to have acquired over the past 8 months)

Unlike most narratives, there is no ending to this story. We just live life appreciating every day, even the shitty ones. I don't think there will ever be a "You're cured" day for us. It will be in the forefront of my mind for the near future, then maybe move it to the back shelf in my brain, then someday, God willing, we can have a day where we don't think about it.

Since starting this bog, I have learned that I am not alone in this. Many friends I haven't seen in almost 20 years have contacted me and sent their well-wishes and prayers, and it was this blog (and Facebook) that made that happen. Someday, hopefully, our experience will resonate with someone else going through what we are going through. Until then, I will continue to write as we find our way through this journey that fate has chosen for us.