Almost One Full Year

This May 27^th marks the close of my first year of blogging. I got into it by happenstance. Last May I was adjusting not only to entering the clinical trial at UPenn but also to the ambitious cross-country travel for this experimental treatment. I was hobbled by my first bout of bursitis. Not able to move, I explored the world of blogging until I had my own site. (Thank you, WordPress and Kim W.!)

The blog expanded the world I communicated with beyond the valiant friends and family listening in via my Caringbridge site to whoever might want to find me. I am still learning the value of tagging each post so that folks able to access the Internet, whether in Isle of Man, Belarus or Palestine, can find my Livingly Dying blog.

There have been 33,160 visits to the site and while 27,144 originated from within the United States, 6,019 came from another 101 countries.

I like to think the blog lessened other people’s isolation with disease. This blog certainly reduced my isolation. Thank you for the comments, insights and support. I also hope the blog championed the possibilities of clinical trials and immunology even as it offered an overly realistic glimpse at challenges of trial participation that required significant travel.

A year ago, paperwork was just signed making me officially in the trial. I awaited my Apherisis on May 22^nd to gather the dendritic cells to combine with my harvested tumor for the kickoff vaccines the first week of June. The year was filled with the predictable highs and lows of a terminal cancer patient choosing an ambitious Hail Mary pass.

This week I officially enter an observation phase. It has already been two months since my last treatment and the deleterious effects of the drugs are waning. My ca-125 continues to rise and is now at its highest point since frontline treatment. What should trigger concern means less because I am an immunological experiment – and science is beginning to see that patients undergoing immunology don’t always have a steady or fast path towards cancer stability. Rather, my body might be learning, which is good, and part of that learning is mastering the skill of recognizing and then eliminating cancer as happens in a healthy body. For those who love to understand, watch this scientist-to-scientist video explaining the emerging breakthroughs of immunotherapy http://www.scientificamerican.com/article/wolchok-video-who-knew-cancer-has-an-off-switch-video/

I will not be retested for months – a thrilling release to enjoy my first break from treatment since I started this journey with metastatic cancer four years ago.

I intend year two of the Livingly Dying blog to focus on rebuilding and thriving as I work to extend my own break from treatment with expanded efforts in self-healing. If you have your own thoughts for what you would like to see more of on this site, please share.

Warmly, Marcy

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Cone of Happiness

It is with great relief and gratitude that I close out a year of arduous and, possibly, effective treatment treks from Oregon to Philadelphia for my recurrent stage iv ovarian cancer.

Cone of Happiness

I first arrived at UPenn’s Perelman Center for Advanced Medicine on April 4^th, 2013. It had taken me twenty months to qualify for this tentative visit. Paperwork was signed on May 8^th, Aphereisis #1 completed on May 22^nd with my starting round of treatment June 5^th and 6^th of 2013. On March 12th and 13^th 2014 I completed my 15^th trek to Philly and my 11^th round of treatment not knowing it would be my last. But it looks like that was my closing treatments for the part one of this clinical trial! Wow!

It’s been a complicated month since I lowered the Cone of Silence. It is never easy to interpret test results without the hands-on experts leading you and my great UPenn doc was gone until April 10^th. The Internet told me a pericardial effusion was a bad sign. On April 17^th, my doc could finally advise me from looking at the actual scans that the size of my effusion, a mere 1-2 cm of fluid around the heart, was not a concern. (Another probable side effect of Avistan.)

While waiting to understand my March test results, my body was increasingly crashing from the burdens of Avistan, a drug I knew I was set to go off, which tempered my complaints. What I did not expect was on April 10th UPenn offered that in lieu of dropping Avistan, they would give me a month off of treatment and add a day to my next proposed treatment cycle to determine if they could administer the Avistan. My heart dropped a little. I wasn’t sure I was up for more travel and more Avistan but I did not want to be cavalier about stopping participation in this trial given all that it has meant for extending my life.

Luckily, I had an appointment with my Oregon oncologist scheduled for the next day – my first visit to OHSU (Oregon Health Sciences University) in a year! As I biked to OHSU the next morning I found tears of joy on my face – it was wonderful to be enjoying a commute to my medical world. Entering OHSU-land (the largest employer in the city of Portland) I was awed by how affirming I find this community. I park my bike with hundreds of others. I get my free ticket for a jolly tram that arrives like a descending sculpture over my head and takes me to the top of the hill as if on an adventure versus a medical treadmill. It’s Tulip Sales Day so bright colored blooms are being sold for five dollars to support some good cause. My appointment is in the women’s center, which offers huge windows, a play area for children and adults on a wrap around balcony outside, all taking in the awesome view of mountains. Every moment at OSHU gentles the medical woes with positive possibilities. It is not so bad being sick amid a culture dedicated to hope and zest. Oh, I wanted to come home for treatment.

My appointment started early and my lovely, calm Doctor arrived with all my recent test results and said, “Wow, aren’t you doing great!” I explain that I have four vaccines left and she asserted before I have even biased her answer, “No, I think you are done. I think you have chosen a resolute and courageous path. You have gotten a lot of benefit and you will probably get no more.” I could have jumped in her lap and wept. Instead I listed my medical woes and she decisively attributed them all to Avistan, a drug she also believes in and dispenses often. But my body needs a break.

I await my two great docs deciding what is the proposed treatment plan for me here in Oregon. It is now my body’s turn to prove what it has learned from the Part One Autologous OC-DC Vaccines. I intend to cheer on my rebooted immune system in tracking down and eliminating new ovarian cancer cells. Or I may recur and get in line for a return to UPenn for the Part Two T Cell Infusion. I am fortunate to count down to either option.

May we build a world where all diseased people find they have positive options for getting diagnosed, finding treatment options and not being burdened with a payment plan. Thanks to this clinical trial, I might have a bit more time to contribute to that effort! Let’s add that to my to do list. much love, marcy

New To Do List

Immunotherapy Rocks

Immunotherapy rocks or, in the more restrained but equally enthusiastic language of Science Magazine, “Cancer Immunotherapy is the Medical Breakthrough of 2013.” From a press release,

“The editors of Science magazine picked cancer immunotherapy as 2013’s major medical breakthrough achievement. Cancer immunotherapy is the use of the immune system to fight cancer. This is done by stimulating the patient’s immune system to attack cancer cells. According to an article on NewsObserver.com, “Scientists have thought for decades that harnessing the immune system to battle tumors should be possible, but it has been incredibly difficult to make it work.”

“So far, this strategy of harnessing the immune system to attack tumours works only for some cancers and a few patients, so it’s important not to overstate the immediate benefits. But many cancer specialists are convinced that they are seeing the birth of an important new paradigm for cancer treatment,” said Tim Appenzeller, chief news editor of Science magazine (1).

Cancer researchers say that they “have turned a corner because two different techniques are helping a subset of patients. One involves antibodies that release a brake on (or stimulate) T cells (a type of white blood cell), giving them the power to tackle tumors. Another involves genetically modifying an individual’s T cells outside the body so that they are better able to target cancer, and then re-infusing them so they can do just that. (2).

I love being cutting edge but I love more the prospect of living with this disease versus dying from it. As a cancer patient who has experienced treatment that didn’t work (scary!), the jury stays out on how I will respond to immunotherapy. My fingers stay crossed.

As the Science Magazine experts themselves debated,

“In celebrating cancer immunotherapy—harnessing the immune system to battle tumors—did we risk hyping an approach whose ultimate impact remains unknown? Were we irresponsible to label as a breakthrough a strategy that has touched a tiny fraction of cancer patients and helped only some of them? What do we mean when we call something a breakthrough, anyway?”

But then they went on to say, “Ultimately, we concluded, cancer immunotherapy passes the test. It does so because this year, clinical trials have cemented its potential in patients and swayed even the skeptics. The field hums with stories of lives extended: the woman with a grapefruit-size tumor in her lung from melanoma, alive and healthy 13 years later; the 6-year-old near death from leukemia, now in third grade and in remission; the man with metastatic kidney cancer whose disease continued fading away even after treatment stopped.

As the anecdotes coalesce into data, there’s another layer, too, a sense of paradigms shifting. Immunotherapy marks an entirely different way of treating cancer—by targeting the immune system, not the tumor itself. Oncologists, a grounded-in-reality bunch, say a corner has been turned and we won’t be going back.”

The full text of their thinking is fascinating and worth a read. It is time to celebrate the promise of immunotherapy.

To access my clinical trial took endurance. I not only had to be clinically stable but I needed to countdown to my start date for Medicare, a wonderful government run insurance plan that allowed me to have costs covered even if my care was in Philadelphia. Effective January 1, 2014 the Affordable Care Act (which contains many great improvements even as the rollout leaves us cursing – Oregon being one of the worst states for enrollment fiascos) removes barriers for cancer patients choosing to access clinical trials in state or out of state. Please check out this boring but highly informative webinar that explains cancer care and the affordable care act to look at the list of ways your treatment obstacles may be being reduced right now. Spread the word.

If you know someone seeking a clinical trial I direct you to this resource that I first posted last July.

Finding a Clinical Trial Just Got Easier BY JON GARINN

By almost any measure, clinicaltrials.gov, the website administered by the National Institutes of Health, sets the standard for providing public access to comprehensive information from around the world about research on experimental treatments for an array of diseases and conditions. Yet, despite more than a decade of efforts to improve its functionality, simplify access to its database and synthesize its information, navigating the site can be a challenge.

That’s why a Florida doctor teamed with healthcare professionals from dozens of medical centers, research institutes and medical schools to develop MyClinicalTrialLocator. MyClinicalTrialLocator.com, a site designed to make searching for a trial easier.

Designed for patients as well as medical professionals, the site not only utilizes the government database for clinical trial information but also includes important updates from medical centers conducting the research and enables users to search for trials anywhere in the world. In addition to studies of drugs and medications, the site also details studies of medical devices, procedures and interventions, and lifestyle factors, such as nutrition, diet and exercise. Users simply enter the name of their condition, their location and the distance they are willing to travel. Listings provide a plain-language summary of the trial, including recruitment information, eligibility criteria and contact details.

The service is free, and access is open to any user, though visitors are encouraged to establish an account so that they can save their searches and receive customized email updates and automatic notifications based on their search criteria. To learn more, visit MyClinicalTrialLocator.com.

There is also http://www.cancertrialshelp.org/cancer-trial-search/.

Go find the best match for you or your loved one.  xo marcy

A Big World Made Smaller

Where are Jersey, Tobago and Ghana?  Courtesy of Wikipedia I find answers. 

A. Jersey is a British Crown dependency just off the coast of Normandy, France.

B. Tobago is located in the southern Caribbean, northeast of the island of Trinidad and southeast of Grenada.

C. Ghana, officially the Republic of Ghana, is a sovereign state and unitary presidential constitutional republic located on the Gulf of Guinea and Atlantic Ocean in the Africa frontier of Sub-Saharan Africa.

There are people impacted by cancer in each of these locations, not surprisingly, alas.

       My accuracy in geography is weak. A shower curtain world map entertained me for years but I still failed to orient myself much better. It is a big world with almost 200 countries, shifting borders and new names. What I know is that everywhere on this globe matters, as does each individual. And that everywhere there is life there is also cancer.

       I set up the blog LivinglyDying in June 2013 motivated to share my experiences participating in a Phase One clinical trial. The fact that it was an immunological trial at the top rated University of Pennsylvania with early promising results meant it was on the cutting edge of possible cancer breakthroughs. Ovarian Cancer has not seen a shift in its mortality statistics in 30 years – any breakthrough would be a big deal.

       I did not enter this trial to be a good citizen. I entered it as my best bet for staying alive awhile longer. Such self-centered motivations did not mean I couldn’t ‘share the wealth’ by adding a public communication loop. I set up a blog during a week when acute hip bursitis had me able to do little. It was a distraction versus a well thought out new project.

       I make an effort to post weekly, be modestly engaging and use different content angles to meet the varied interests of readers. Friends, family and colleagues were the first to enroll, motivated to track my progress. I wanted content to be good enough that they might share the link with other’s coping with mortality or cancer or just the wonders of life. As the tagline indicates, the blog promises “notes and essays on daily life with terminal cancer.”

       I learned about blog culture and the excellent tools that WordPress provides so that innocents like myself can build a platform that is read. Little by little, I was found. (I am still waiting for The Post That Goes Viral to bring me instant fame as was so well made fun of on Showtime’s series The Big C. The truth is many, many people blog and many, many people buy lottery tickets – the odds of making it big are not in your favor.)

        I stay mesmerized by my stats page which allows me to study not just the number of visitors and the different places on the site where they spend time but also which countries they call home and what entry points allow them to find LivinglyDying. I am often amused to find search terms like ‘Marcy Westerling’s Obituary’ as the connection to the blog. (Yesterday someone entered ovarian cancer party supplies and found the blog!) More common are search term entries like today’s query, ‘I am dying of cancer’.

       Most of my visitors stumble upon the blog in desperation – they have received their own terminal diagnosis and they want to feel less isolated as they learn how to cope. People from 58 countries including Jersey, Tobago and Ghana have spent time on LivinglyDying. There have been over 13,000 visitors and while that still ranks me as a small potato blog, I hope that in the five months of my blogging visitors may have found some support and useful information.

       Thank you for being readers, for spreading the word. If you are healthy, thank you for being brave enough to co-mingle with those that are not. For those consigned to this sorry path of terminal illness, thank you for reaching out and for suspecting, as I do, that there might be some magical power in being connected and in being emboldened by the notion that in 2013 we can be both terminal and quite lively and that maybe, just maybe we will see our illnesses become chronic versus terminal in our lifetimes, especially if we can make the world a little smaller, share our resources and make every person and every community counts.

Superpatient in Training – The Philly Chronicles – Trek 7

How much long needles going into your non-numbed groin lymph nodes should hurt on a scale of 1 to 10 is negotiable. It does hurt. But mainly it vexes.

First, there is the waiting, as you lie exposed on the stretcher as the team assembles. Always, vaccine number one is being held in the air as the cast gathers. Why not hidden, nestled in its cooler with its sister? I don’t know. Then there is the small talk as I move my head in odd patterns to avoid seeing the needle. I was trying not to be obvious but by vaccine round four everyone knows I hate seeing the needle, not that that keeps it any more hidden. The radiologist is always the last to show, the lights go out and everyone stares at the ultra sound screen. Half the cast watches silently as the doctors negotiate over possible lymph nodes to target. Sometimes it takes a while for a lymph node even to be found. They look at the screen positioned across my belly, a screen that somehow lets them know where to insert the needle into my body below. Everyone judges the accuracy in this mapping negotiation by staring at the needles journey on the monitor – many opinions, one doctor with the needle, though. It is not a fast process. Eventually there is agreement that we are in a node and then, phew, we are done on that side.

It is important not to flinch because then we need to start over and I am a flincher! I try different tricks to anticipate the modest discomforts, to avoid flinching. Closing my eyes does not work. Imagining me on a beach in Maui does not work. Staring at the screen, talking myself through the needles arrival with its small allocation of pain helps. As does reminding myself that this does not need to please me.

There is an expression in Italian I have always loved, “Non mi piace.” It does not please me. I have found it a useful phrase over the years mainly for self-calming as compared to effective communication.

In 1989 I was on a work brigade to Portland’s sister city in Nicaragua, Corinto. The US was at war with Nicaragua. It might have fallen into that category of secret, dirty wars that many in the public miss, but regardless American taxpayers were funding the bombs that were falling. The brigade was to honor the memory of Ben Linder, a young Portland engineer recently assassinated while installing a water system for a small Nicaraguan village. Corinto is a port city sitting on a lovely stretch of open beach and ocean. At the time, all the fishing boats listed uselessly in the harbor. War damage.

The setting should have been enticing but it was not. We were there to work on the hospital. The open-air structure was well worn before the struggles of war. In the initial tour, I appraised the scene and decided I did not want to end up a patient here. The once sophisticated sterilizing equipment was now hauled to an outside fire pit. The surgeon talked about the daily power outages and what that meant with no back up generators and a patient open on the table. Chickens walked inside and out.

I had prepped for the anticipated vigor’s of the brigade by building up my physical strength, not learning Spanish – I had a naïve assumption that my knowledge of Italian would carry me. It did not. My host family was a mother and daughter. They welcomed me into their home, vacating one bed as they shared the other for my visit. A bowl was placed on a stool in the middle of the bedroom at night for toileting. The bedroom door was then locked barring us exit to the courtyard outhouse.

I was far too shy let alone confused by the bowl on the stool to use it. And the outhouse was far from enticing even if it was not an option at night. To boot, there was an incredible lack of potable water in the city due to a bomb hitting the cities main supply line. I decreased my drinking to solve all problems at once. Each day I felt a little less well. One day I felt awful and came down from the roof we were working on to collapse in the shade. It was the kids who realized I was seriously ill as they kept touching me and saying, “caldo.” They alerted adults who moved me into the doctor’s lounge for immediate treatment. My temperature was 105 and I was in preliminary kidney failure because I was not, in fact, drinking enough.

But when they came at me with an IV I remembered my resolution not to need treatment in this hospital but the only words that came to me were, “Non mi piace.” It’s a great phrase but not for communication outside of Italy. After a few days of fluids I was fine and learned a few more tips of self-care even in a war zone.

Back in the United States in 2013, far from any war zone, vaccine round four happened the first week of August. A friend had made me a pair of superman underwear for this round. It seemed borrowing some superpowers might better get me through this process. Vaccine four, I was ready. Two women get vaccinated each day and I had warned my partner of my plan at chemo the day before. She parents a toddler and so was easily able to pledge to wear her own pair because, in her house, every day, they are all matching superheroes! So me in superman undies, she in her superhero of the day, were ready for the vaccine process. Both of us agreed after it was our easiest round of vaccines yet. And that pleases me no end.

Superpatient Panties

The First Vaccine Treatment

The Philly Chronicles – Trek Four, Part B – The First Treatment

The terrain of hope is rocky. My excitement to start the treatment phase sustained me through an uneventful flight from Oregon to Philadelphia. I went from plane to train to the hospital campus to meet an incoming candidate for dinner. Her medical intake had started that day at 9 a.m., making our date for 5:30 seem reasonable. She emailed a series of apologetic notes of delay finally being released from her day of screening tests at 6:15. I recognized her easily by the bandage showing where she had last been punctured. A shared meal of falafel from one of the many food carts was delightful as we exchanged information, motivations and snippets of life stories – cancer serving as the frame.

We bid goodnight and I began my two-mile walk towards my housing with regrettably over packed luggage. Hip and knee pain had me whispering ‘ouch’ with every step. The walk is wonderful, though. The first quarter crosses the smaller of the two rivers that encases downtown Philly. While crossing over the Schuylkill and the expanse of expressways paralleling the river there is an amazing view of down town, a striking skyline. At dusk there is a line up of folks taking photos. The next stretch is dense city, mixed residential and commerce, the standard three stories allowing peaks of the skyline on the left.

The following 7 blocks are not too exciting but then the street life starts accelerating. It is not a boring walk. Public art is everywhere. You can walk the same city block many times finding new things to admire between people watching, architecture and art. Murals dominate. As a quilter I am quick to note that the majority of quilts and murals are, frankly, not too exciting. In Philly I have yet to see a mural that has not met the mark for art. They tend to be three stories high and broad and from what I gather the Philly mural project has engaged a long-term team of artists to guide the community process for each site. The commitment to art and storytelling fuses brightly in Philadelphia.

In no time, I am at my own structure, juggling luggage, keys, and memory to get in the door, up the three flights and then, ‘Hello, roomie – I’m back!!!!”

June 5, 2013: The next morning I was to report in at 10 a.m. I was reluctant to end my long night of sleep – the bed felt too good. Twenty minutes before departure I got up forfeiting food shopping in favor of a quick shower. I should be done early enough to meet food needs. The walk was slow – my aching joints create a pacing that I am still not used to. Nonetheless, I arrived on time.

My handler was there by 10:05. The screening vial of blood was in motion by 10:15 but that would be the last thing on time for the day. Things started going awry. The person that normally did the physicals while patients were being prepped for the infusion was off. I needed to abandon my chemo post and relocate for the doctor. The doctor was busy. I was set in a typically dour examination room to wait and wait I did. After 15 minutes I opened the door to mitigate the stress of the confined space. After 30 minutes time started passing dramatically more slowly, then 45 minutes, then 60 minutes – tension settled in. I was now taking a roller-coaster plunge into the darker side of hope – despair. Why was I here? What life was this? I distracted myself by listing all the remaining things that could go wrong that day sidelining chemo, putting the scripted protocol off kilter and exiting me before even starting this foolish Phase One path.

The charm of the arriving doctor evened things out some. The exam was done in minutes, I was cleared for chemo and a new nurse sent me back to the chemo-waiting lounge. Like I knew where that was in this inner maze of the building. I stumbled back, unraveling. It was now past noon and it was clear that these accumulating delays meant that I needed to find food before I was strapped into my chair for god knows how many hours. I also needed to breathe a moment of fresh air of the delightful day outside if I was to regain calm.

I got a small bite to eat in the sunny warmth then reported back in only to be told, “sorry, there are computer problems preventing your clearance for chemo from showing up.” I convinced them to call me when the problem was resolved and ran outside. I found a patio that allowed me to stay close to my bank of elevators but enjoy a sense of normalcy. It would be ok, I kept assuring myself.

The call came clearing me and at 2:00 I was being seated in my chemo room. The next struggle presented itself. One of my infused drugs, a drug I hate and have had for over a year, would need to be infused over 90 minutes instead of 30 because they insisted on treating me as if I had never had it before. That was absurd. It was getting late. I challenged the edict requiring phone calls. Meanwhile the nurses were being sprightly in hearing me beg them to get my port accessed, start the pre-meds and leave me to the negotiations.

The nurses were wonderful and did their best to zip my infusions through but the mandated avistan drip speed from 30 to 90 minutes held firm because of the stupid research protocol. I hate rules based on weak footing. Someone showed a lack of imagination when crafting that section, and I lose another 60 minutes to hospital life. It adds up.

But protocols, once written, cannot be changed with ease. A research protocol risks termination with every change. I got to fume at what I experienced, which is genuinely frustrating, knowing when calmer that it is just the architecture of checks and balances within research. It is what you sign on to. Hope and frustration!

Infusion done, released, I delight at the smells of a tree in bloom. I breathe in life. Outside I am content, confined I agitate. Computer systems went down, the wrong people had a day off and the relentless rules that indicate you are the property of research combined to make my first infusion an all day affair. It was a beautiful day just as it was beautiful the day I flew. It’s summer, time to be outside but not for this research subject. I am relegated to the various benches for the permanently waiting.

Vaccine day – June 6, 2013: I trudged back to the research building. This day was cool and gray. Without the usual cushion of steroids infused with yesterday’s chemo, I felt gray as well. (Steroids are barred since they suppress the immune system and this trial is about building the patient up.) I had not experienced this level of exhaustion for quite a long time. Dressing that morning required breaks lying down.

The vaccines were a big moment, I had worked for 20 months to get to this point but having emotions was beyond me. I was too tired. I arrived to my waiting area the required 30 minutes early. The Paris Open on TV held my attention as I also tracked the room. Not many people, in fact just one other woman roughly my age quietly speaking with a friend. Hmmm. I peaked to see if she had the same envelope I did but nothing showed. The doctor came out saying, “Good, you are both here.” He graciously came over to me, the vaccine first-timer, to shake hands and assure me this would be easy. Then he took time with the other woman. As soon as he hurried out “to get things started,” we exchanged names and emails before we were whisked to our different rooms. She was the patient enrolled immediately prior to me, the second in our cohort. There was little time for other details as a parade was starting.

At the head was the ever-cheery Dr Tanyi, then support staff with coolers, clipboards, then rolling machines. We were told to get in line as we walked down a hall to a new section of rooms. The other woman urged me to go first knowing that first time jitters would only settle down once it was done. I was ushered into a tiny room now filled with parade participants plus some new folks. I didn’t know what to do until someone indicated that I should get in the bed. A bed, I hadn’t expected that. Given my exhaustion the sight was most welcome. I was shaking hands with old and new staff while trying to maintain some dignity as they all formed a tight, tight, tight semi-circle around me. (Think room as small as an elevator now including a bed, equipment and 8 people.) My lead nurse was holding a large syringe in the air. I make it my business never to look at needles but in this tiny room it loomed large. The other one must still be in the cooler.

I lay down, draped with a blanket as I scooted my skirt down. The doctor kept patting me saying, “This will be just fine, you’ll see” then quickly turning to a peer, narrating the process. She was being trained in, it turned out, to take over while Dr Tanyi was gone the next month. Damn, I don’t want her to be trained in on me! My undies were protected with napkins as goop was placed on my inner thighs. The ultrasound beeped to my right as we all waited for the radiologist to arrive. It was a long five minutes of trying to avoid looking at a needle held high – of trying to preside with grace as the centerpiece of the room. Radiologist in place, I fixated on the ultrasound screen wondering if we might find a baby but the search was for lymph nodes. “Ah”, I heard but I saw little amid the gray striated screen. When would the needle go in? Ouch, it was going in and that I could see on the screen. It was a slow process of everyone agreeing that it truly was in the lymph node and then that vaccination was done. Next side and it was now the doctor-in-trainings turn. I would have loved a sound bubble rather than hearing the list of do’s and don’ts as a much, much slower process started on my right. Was she in the node – were they really going to discuss this endlessly with the needle in me? Finally, the slightly more painful vaccination on the right was done.

The parade director put the sides up on my bed, and wheeled me from the vaccine room into another room for observation over the next hour. At 2:30, I was dismissed from the bed and faced five hours of walking around counting down until time to return for a blood draw. The weather had shifted with tropical storm Andrea arriving. I had a list of places to explore but my bag was heavy and I wanted to lie down. The University of Pennsylvania is a beautiful campus but there was no place comfortable for my post-chemo body for more than a few minutes. The temperature kept dropping. The clouds grew more ominous. I wanted a bed.

Eventually I got the 7:10 pm (protocol forgot to allow a window) blood draw and started my slog home in a drizzle wishing I hadn’t been so confident this morning that it wouldn’t rain. Home at 8, too tired to eat I went straight to bed sleeping until 9:30 the next morning. I awoke feeling better. In fact, my hip pain of April and May seemed gone. I was still tired with nausea but within acceptable limits. I relaxed with my roommate, packed then headed out for the final blood draw at 1:10 p.m. exactly. With all my luggage and tempestuous rains starting outdoors I grabbed the train to the airport. It was a direct flight home escaping just before the storm hit full force, arriving into the arms and care of my husband. Tired, nauseous but miraculously clear of hip pain – a benefit it seemed of the cytoxan chemo that, apparently, can be used for arthritis. My first treatment trek was done.

The Philly Chronicles – Trek Four, Part A

Monday (6.3.2013) dawned gray in Portland rather then kicking off the predicted suite of sunny days. The forecast had been revised overnight. I have yet to give up trying to control the weather, a habit I developed upon moving to the rainy part of the Pacific Northwest. The rain is fine, the gray can be gorgeous but my disposition is for sunny and warm – I never tire of it.

May weather was especially harsh to accept after a remarkably dry and blue-sky winter and spring. This May ended up being the third wettest on record. And cold. The nation suffered big weather turmoil while we just coped with the grumpiness of winter weather in spring. So yes, I counted down to my one sunny Oregon day before bidding goodbye to fly back to Philadelphia – more planes, airports and hospitals in store for me. The sun did sneak out albeit a few hours late. I thrilled in its arrival.

Between chores outside I toured the different nooks that make up our small urban homestead. I love to greet the flowers, their beauty deserving a small shout out. I am less outgoing with the vegetables and fruits, the exception being our young apple trees promising an actual crop this year. We moved to the city when I got my stage iv cancer diagnosis three years prior, leaving behind our dream farmstead with my flock of ducks and the ever expanding orchards and growing beds my husband fed us from. We planned to grow old there. We lost several dreams with the arrival of cancer.

I never really went home post diagnosis. Dear friends literally met us at the emergency room where doctors were puzzling out my collapsed lung. It would take a week for diagnosis but after removing liters of fluid from my chest, they whispered in the hall to these friends that, ‘there was never a good explanation for a collapsed lung.” We stayed with these friends that rocky April filled with all hours of trips to emergency rooms and then the pronouncement of terminal cancer. We stayed with them in an ad hoc guest room for the duration of front-line treatment. It insured care and laughter during a bewildering few months for my husband and me.

With the cancer diagnosis I committed to staying strong and for me that meant easy (aka biking) access to medical and complimentary care and, frankly, the busyness that a city offers. Depression seemed a secondary threat. It was time to say goodbye to the greater isolation and distances of country living.

Our new home, small and perfect with a decent allocation of land, steadily took on the shape of our revised dreams. Two vegetable beds were squeezed into the side yard, then three on the sidewalk meridian, two community plots acquired nearby and the expansion continues, a source of shared delight. I know every square foot of it very well.

Monday, soaking up the sun in preparation for my flight, I discovered a hidden treat. We had pruned out some trees blocking the southern sky last winter, now rewarding the effort was the most subtle and stunning iris blooming where a few trillium lounged months back. I took a photo to take with me on my travels.

I start this trek (Tuesday – 6.4.2013) with excitement. Finally, I begin the multi-day process of treatment in this phase one trial. A chemo cocktail of cytoxan and avistan day one, vaccines to the groin day two, and for this first cycle – blood draws every 12 hours for an additional day. Then home where I hope the sun and the iris will still be holding court.

I travel with Roxanne Cousins. She died earlier this year at age 40 leaving a young son to do his best with memories. Roxanne and I both worked hard to qualify for this trial, sharing notes and encouragement along the way. After surgery she was told that she didn’t have enough volume to meet the damn criteria. She was determined to try again; to get in this trial; to buy some more time with her loved ones. The cancer claimed her before another surgery could happen. I pledged to keep her spirit with me in a trial that is too early on to promise miracles but those of us with ovarian cancer just seek time extenders.

The Sunday N.Y.Times (6.2.2103) covered the interesting challenge of HIV patients in the U.S. once short tracked for death while often in their 20s and 30s, the miracle arrival of their own cocktail and the problems they now face of aging after decades on treatment. They featured one such man who was extremely close to death when the call came about ‘miracle pills.’ Within weeks he was gaining weight and mobility. Decades later, he lives. What a concept. Imagining that process occupied my mind. Of course, he couldn’t know it was a miracle at the time but must have considered it as a weak possibility. How long did it take him to accept this drastic change of fate? Could he ever revel? Does it matter?

What terminally ill person has not awaited a clarifying call in the months after diagnosis offering a reprieve? “So sorry, but you really have this other more benign calamity to contend with.” I met a woman who got such a call – it only changed her from a stage 3c to 2b but in the terrain of hope that is huge. With this trial I enter the terrain of hope.

Part B to follow shortly…

The Philly Chronicles – Trek Three

I have now completed 3 visits to Philly – all equal parts pleasant and hard. It is crazy to commute cross-country for medical care. I *hope* that my next five visits to Philly, which all involve predictable treatment, will be easier then the prep visits filled with the uncertainty of passing criteria. But these are the delusions with which I pattern my life – not that such optimism does much harm.

Anyway, after three cross-country trips in a month and a half, the clinical trial physical prep work is done! My next visit the first week of June is for treatment – travel the 4th (sigh), chemo the 5th and vaccines the 6th. The first round I stay an extra 24 hours for observational blood work meaning that I travel home the night of the 7th. I have found April and May overwhelming with the travel tipping the scale.

I do feel relief to have to prep work done. The ‘dreaded apheresis’ was completed May 22nd at 2:30 pm. They only allow you a specific amount of time on the machine. I wanted to stay on longer to reach the high end of the goal of having had 15 liters of blood processed but the cut off time was marked with the arrival of the research staff to carry off the tiny bag of dendritic cells that go right to the lab for processing. Interestingly, I have since learned that the average female has 4.7 liters of blood in their body so the time is all circulating the same liters of blood to extract, extract, extract. My body generously allowed 13 liters to circulate, three more then the ten minimum needed. (As you can see, I do most research after undergoing the procedures but understanding a central line, I think I will avoid.)

Getting the central line was no fun. I relied on the information they provided that said it would be quick and uncomfortable versus painful. It is quick if you don’t count the serious prep time in the surgical outpatient wing and actual operating room. In some Merriam Webster dictionary way it might qualify as uncomfortable but in the real world of being lashed down to an operating table 2000 miles from home, it is a way creepy experience made more disconcerting when they need to abandon their initial plan of ‘vein preservation’ (a heartening concept) and reverse the operating room equipment to accommodate the ultrasound showing that there wasn’t any vein to preserve on my right side.

Two realities made the procedure harder. My email went down for twenty hours. Worse yet, I had grabbed the wrong charger so despite keeping my equipment off to maximize battery life, I had no juice by the morning of the procedure. My sister-in-law, driving 4 hours each way from upstate NY to provide support was bringing me a cord but we first had to find each other.

The plan had been to meet at the Apheresis Unit in the hospital to spare Peggy the chaos of tracking my complex morning moves through different buildings. But, of course, I needed her support at surgery. She figured that out (Peggy is incredibly competent and cheerful!) but she was only able to snag me as I exited with my central line installed. Within 30 seconds we were laughing and on our way to the waiting Apheresis Unit. (I could bore you with how to registration gal ‘lost’ my paperwork thus delaying the installation of the central line and increasing my tension but….you can imagine.)

Everything at the Apheresis Unit was easy. They know their stuff. The research team and they had interfaced perfectly. They have a very high staff to patient ratio. I had spent the week prior being perfect in what I put in my body. Peggy showed up like a salesperson for naked juices – one in every color, which I dutifully drank down. They opted (based on labs?) to infuse throughout different extras like calcium rather then waiting for possible mini-crisis’s. It was pleasant outside of the modest discomfort when talking and swallowing. I tried not to resent the window with the great view of downtown Philly in the sunshine being blocked by my bed. (Why do they do that?)

They informed me that I was extruding the perfect color of cells so that cheered me on. They knew I was flying out that night and did a lot of additional care to assure that would be fine. (Although it was not entirely confidence inducing when they packed a little post-care bag equipping me to staunch any blood flows and when I asked what I should do if I couldn’t stop the bleeding, they responded, “go to your nearest emergency room with your paperwork.” Hmmm….)

A mini-drama started two hours after boarding the plane. The weather in philly was wonderfully hot, my clothes were slight and my bandage was HUGE and mandated. I walk with a cane right now and always use a facemask in airports and planes as advised. My hat sports the cancer sucks button. I realized I looked worrisome both coming and going, as airport personnel stopped to ask if they ‘could help?’, I was escorted to the disabled line and wheelchairs were waiting for me at the close of every flight (I refused them but I did avail myself of the little trolleys for the first time.) So, I entered my first leg plane, as an obvious high need person. After the close of the first hour and a half on the tarmac, knowing I had a mere 45 minutes layover in Phoenix, I rang the call button, another first. The attendant came and I explained that I was a cancer patient returning from treatment and that I had a medical team in Philly and one in Portland but none in Phoenix and I did not want to spend the night in the Phoenix airport. They were vary accommodating but were clear on their limitations and gave me five minutes to mull if I wanted to deplane so I would be with one medical team. I was overwhelmed and knew that a. an off loaded passenger requires the re-inspection of all stored bags, a multi-hour delay and b. getting back to my host lodging was a decent undertaking for an exhausted person not allowed to carry anything for 24 hours and c. I wanted to get home. My seatmate, a man of roughly my age volunteered softly spoken council that would make any feminist proud. The flight crew was strong on encouraging if I had any discomfort I should deplane. I couldn’t have had better support. In the end, I decided to gamble that enough people now had my back that I would stay the course. The flight crew kept me posted, moved me to first class for the landing so I would be the first off, alerted the Portland flight and whisked me to the gate. The second plane landed only 10 minutes late. I was in bed with Mike at 3 am, 6 am philly time. What an amazing 24 hours in the pursuit of survival.

And all that night my sack of dendritic cells were in the lab growing into the marcy vaccine.

It is fun getting to know a new city. It helps that my guest accommodations are wonderfully situated for pretending I am on vacation. The condo is located on South Street near 12th – a central, fun, big city neighborhood. It is a row house befitting the city style and we are on the top, thus third floor. The terrace looks down on the street hubbub and this last trip, with bursitis limiting my movement, I adored leaning out over the block and creating storylines for the strangers I am getting to know through persistent observation. The extended family of three plus generations that runs the convenience store and seems to preside over the block – who parks where and when, with ample home cooked meals seeming to be the reward for following their rules. A nail salon and the day care center provide intermittent distractions that I am piecing together.

The lovely home setting complete with a warm host compliments the rigors of travel. Cross-country medical care may be nuts but amenities like these lull me into the pretense of being on vacation and, of course, you travel for that.

Onwards to more vacation the first week of June!

Warmly, marcy

p.s. snippets: I am finally noticing an abatement of my chemo induced shortness of breathe – yeah! I also greet the arrival of new hair filling in my scraggily scalp just in time for a possible new round of thinning as I start a new chemo drug with that side effect June 5th. I intend to return to full mobility in the next month or so. It’s been demoralizing to watch my chemo induced hip arthritis aggravate into acute bursitis but it too can be managed.

The Philly Chronicles – a start

My ovarian cancer recurrence in October of 2011 condemned me to the predictable but somber reality of life in treatment. My care team and I selected the Penn trial as the hail mary pass best suited for me surviving longer in this reality. Frankly, there wasn’t an extensive menu of choices. Many other women reached the same conclusion creating a line of hopefuls since winnowed down by the ravages of this disease and hefty qualifications. This week, 19 months after starting the process, I signed the entry paperwork with very little fanfare.

The final countdown to entry allowed me the first moments to switch from ‘must get in’ mode to ‘holy shit, what the fuck am I doing’ mode. It hasn’t made the trial any less compelling, just made my ability to survive the rigors of cross-country medical care a concern. Anyone who knows me knows that I am the ultimate homebody. Additionally, I crave open windows and being outside. Airplanes, airports and hospitals are the worst form of punishment.

Now I consign my high holy months of summer and fall to endless air travel interrupted with endless hours in the hospital. Palliative care patients are counseled to select quality of life since quantity will elude us. The quality/quantity tradeoff is complicated by hope – might I get a bit more time by sacrificing my quality? A more amusing tradeoff is the irony of my lifelong politics prioritizing local solutions (before it was cool) and now I select the least local medical care possible.

I completed my second trek to Philly this week. In the eleventh hour I cancelled months of detailed planning that had me scheduled to stay east between the two May appointments. I got seriously ill at the end of April, which humbled my pretensions of strength – I bought a new roundtrip ticket with bad seats and high prices, as I needed to come home.

My relationship with the travel gods has always been tenuous. It’s like they pull out their most mechanically flawed planes when I show up. They fix them, which is nice, but not before hours are added to the journey. The Houston leg of my late night trek home included several hours circling the city to burn up enough fuel to allow a safe landing and plane change. I crawled into bed at 5:30 am Philly time – a long day by any standards and my standards are not normal.

A month in and I am learning my Philly landscape – who gives reliable answers, what will happen each visit, how to navigate the city and where I sleep.  It’s a pleasant city that I have walked enough to feel oriented. My volunteer host is well situated and generous. More importantly she has windows that open! A tiny terrace!!! I can walk the two miles to my treatments!!! These details mean a lot.

For much of my treatment I have opted to go solo. Getting medical care is my new job and people go to their jobs unaccompanied. Furthermore, I hope to extend this into a marathon versus a sprint and that means rationing how I complicate other people’s lives. But I am now realizing there is a big difference between going solo a few miles from your home with a rolodex of allies willing to be on call as needed. In Philly, I am a true solo act. There is no back up plan. Yet.

Mike can’t stand not going with me but I remind him of the importance of some stability and normality in our lives. He serves as the safe harbor I throw my mind to as I miss my life. I visualize him living for the both of us. He is the person who tends my every need when I am home but we still have enough balance that he stays my lover not just my caregiver. He attends all decision-making appointments but that’s it. I draw lines. They help me cope. But I missed him horribly this last trek.

Luckily, Philly is a fun city just $8 by bolt bus from NYC and other settings. I hope to explore having an east coast care team that can break up the monotony and challenges of this trial so far from home. (Any takers out there?)

The apheresis is next on May 22nd. It’s the dreaded procedure where 10 liters’ of my blood will be removed then returned minus dendritic cells. It’s hard on any body and mine was fragile before I started three years of treatment. My sister-in-law is driving down from upstate NY to share her competence and cheer. I leave for the hospital at 6 am, with all my gear (100% roll-able because I cant carry anything afterwards.) My plane departs at 8 pm that night returning me home at the alleged hour of 4:30 am Philly time. A long day. But then the hardest part is done (hopefully to be re-done only one more time in September.)

The first week of June I return to Philly to start actual treatment – chemo one day, vaccines the next then observation then HOME for 3 weeks! I will learn how to master this trial, the travel and ways to keep this a journey I chose – one that need not just challenge my quality of life as I barter for more time.

I close by sharing the invaluable words of Susan Gubar a colleague in living with incurable ovarian cancer. She blogs about her journey at the NYTimes capturing so many of the complicated emotions and body issues that I face right now as she talks about her life in a clinical trial. I say, ‘ditto.’

much love, marcy

MAY 9, 2013

Living With Cancer: Good News Soup

By SUSAN GUBAR

People with incurable cancer do sometimes receive good news, as I have. Why is it harder for me to share good news than bad news? During treatment, good news produces elating highs, but also anxious lows.

When I entered a clinical trial for a new cancer drug, the consent form stated that the medication would not provide a cure and could kill me. The pills’ effects on my ovarian cancer were to be measured by the CA-125 blood test, in which numbers above 35 indicate disease growth.

I started the trial last August with a CA-125 over 100. As the number fell in the autumn to 38, in the winter to 9, and in the spring to 5, my morale rose – tempered by occasional dips and drops.

My family and friends are ecstatic. So is my oncologist, who wrote in an e-mail: “You do not even know how exciting it is to see the results of this new drug. I do a lot of clinical studies and I see so many negative results, some of which are fatal. We do all that work to get one rare patient who gets benefit … very rewarding to see it happening to my friend!”

The last two words of this message touched me to the quick. After four years, Dr. Matei had entered my heart and (apparently) I hers. A great joy to make a new friend at my age and in my situation, especially a friend so admired.

Yet I worry that I will fail her. A number that descended in the past nine months can ascend in the next nine months. (Overwhelming odds are it eventually will.) Might sharing good news jinx it — turn it, in the blink of an eye, into bad news?

I know from the nurse administrator of the trial that the experimental drug is not benefiting women with breast cancer. My good news makes me distressed about their bad news. Also, I had overheard conversations in the hospital waiting room about other ovarian cancer patients dropping out because of deleterious side effects, some of which I experience.

Weak from months of dosing, I cannot stand on my feet to cook for more than 10 minutes at a time. At the supermarket, I ogle ready-made meals. Changing the sheets on the bed requires time-outs. Filling the bird feeder, hauling it out, bringing it back in at night (so the squirrels can’t raid it) takes too much fortitude. Bones ache that I did not know I had. My hair has thinned so drastically that Joanne at the salon clipped it close to the scalp, all the while lambasting comb-overs.

Diminishing the cancer seems to involve depleting me. Still, I have kept my resolve steady by focusing on the satisfaction of contributing (if only in a minuscule way) to medical research. I had also kept myself on an even keel by hunkering down for the worst.

Now, with the best possible results, I am a neophyte who does not want to be an ingrate. My trepidation at the lowering cancer marker reminds me of the angst recounted by many patients at the end of a round of successful chemotherapy. The gift of time starts to feel like a present spoiled by uncertainty about the future. With cancer, you can’t win for losing.

Yet today I would rather be a cheerful Tigger than a gloomy Eeyore. So to buoy myself I decide to use the chicken stock defrosting in the fridge, its fat congealed on the top, to make matzo ball soup for my visiting daughter and son-in-law.

After I toss most of the fat, saving a tablespoon, I start whipping up the egg whites. But one of the rotary beaters of the electric mixer refuses to stay in its socket; it keeps falling out, no matter how I swivel it. I am here to testify that the gizmo works with only one beater. That, too, feels revitalizing, even though my low numbers and high spirits may have started to change on the day you read these words.

Tonight there will be homemade soup. Tomorrow I’ll put out the bird feeder and leave it out, despite the squirrels.

http://well.blogs.nytimes.com/2013/05/09/living-with-cancer-good-news-soup/

 

Big News Story – Immune Therapy Offers Hope in Ovarian Cancer

Preliminary trial results were released on Saturday to great fanfare. Here is an article for those who like details.  xo marcy

Immune Therapy Offers Hope in Ovarian Cancer

By Michael Smith, North American Correspondent, MedPage Today

Published: April 07, 2013

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Action Points

• Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
• A novel two-step immunotherapy process appears to be effective in nearly three-fourths of women with advanced ovarian cancer when combined with chemotherapy.
• The process begins with treatment with a personalized vaccine derived from the patient’s own dendritic cells and is followed by a second step, called adoptive T-cell therapy, in which immune cells are reinjected into patients after being removed, stimulated, and expanded in the laboratory.

WASHINGTON — A novel two-step immunotherapy process appears to be effective in nearly three-fourths of women with advanced ovarian cancer, a researcher said here.

The process begins with treatment with a personalized vaccine derived from the patient’s own dendritic cells, according to Lana Kandalaft, PharmD, PhD, of the University of Pennsylvania.

In 65% of 31 patients in a small nonrandomized trial, the vaccine alone led to either stable disease or partial response, Kandalaft told reporters at the annual meeting of the American Association for Cancer Research.

A subset of 11 patients went on to the second step of the process — called adoptive T-cell therapy — and 73% had what Kandalaft called a “clinical benefit” — either stable disease or a shrinking of the tumor.

Most patients with advanced ovarian cancer relapse within 2 years, she noted, and most die within 5 years. “There is definitely a vast unmet need for the development of novel, alternate therapies,” she said.

The process appears to offer new hope for patients with recurrent, progressive ovarian cancer, Kandalaft said, adding that some participants in the trial have had stable disease for several months.

Indeed, she said one woman, who had relapsed twice and had undergone three debulking surgeries before being given the dendritic cell vaccine, has now had 45 months of progression-free survival.

“To this day, she’s still in quite good condition,” she said.

The role of dendritic cells, she noted, is to act as “spies” — collecting information about potential targets and bringing the data back to the T cells, the “soldiers” that kill those targets.

In the study, Kandalaft and colleagues kept participants’ tumor cells alive after debulking surgery and then isolated dendritic cells through apheresis. The cells were exposed to tumor antigens and then injected into patients’ lymph nodes, along with intravenous bevacizumab (Avastin), over about 3 months.

In 20 of 31 patients, Kandalaft reported, the vaccine alone led to clinical benefit — 17 patients had stable disease and three had a partial response. The vaccination was well tolerated and elicited tumor-specific T-cell responses against various ovarian tumor antigens, with some patients experiencing prolonged progression-free survival.

The 11 patients who went on to the second stage of the process had their T cells removed, stimulated and expanded in the lab, and replaced in large numbers. The transfer amplified the antitumor immune response, Kandalaft reported, because the T cells had already been educated by the dendritic cell vaccine to attack tumor cells.

Of the 11 participants in the second stage, seven had stable disease and one had a complete remission, she said.

The study “shows that it’s now possible to devise very efficient and complex but feasible combination strategies (starting with) a vaccination that will basically point the immune system in the direction of the tumor,” commented Louis Weiner, MD, of Georgetown University here, who was not part of the study.

“And then you can further expand that response in a very productive and useful way through an adoptive transfer of activated T cells that have been educated to attack that particular set of antigens,” he told reporters.

Such a combination approach, he said, has the potential to “overcome some of the innate resistance mechanisms that cancers use.”

To Philly and Back!

I got a taste of my possible new normal last week and it wasn’t bad. In fact, it felt a lot like my old normal, a life I did quite love. Facing mortality I am determined to enjoy whatever each day brings, but that attitude can belie a deeper truth of who I truly am and the life I would like to live. I like being engaged, busy, in the thick of things. I have adapted well to being ‘in the thick’ of life on the infusion ward and the acupuncture clinic but there is a bit of guise in that.The week, starting with last Saturday, March 30th, was BUSY. I knew it would be, so trying to ration my energy, I had even asked my dearest friend not to fly out for my birthday party (sigh) fearing a visit on top of big events would be too much. Even with Stephanie not joining us from Minneapolis, it was quite the gathering. People drove in from many directions to create such a mass that few individual conversations happened but oh what a mass of energy and fun – what you would hope for at a dance party.

The space was lovely, the weather beyond perfect, the host team award worthy and a cake that I never got to sample perhaps in an inadvertent boycott of the cutting into such a thing of beauty. The cake was massive and covered with the ‘best of’ photos of yours truly collaged artistically together.

I stayed on the dance floor and despite my fears that my lung capacity might reduce my ability to boogie, I did not return once to the designated ‘marcy rest throne’. It was wonderful dancing with so many dear friends. At the height of the evening some loud bangs erupted. Oops, the accumulated sound had detonated a few wine glasses. It was time to start winding down.

I had a day of rest before flying off to New York City. Two big east coast events had been foisted together without much ease. The first was a two-day conversation closing out a two-year thinking/action project on engaging the white working class in progressive identity. ROP was among four other groups to feature their work. It was a typical such gathering – 12 hour days, an expectation of your mind always being on.

A special needs person such as I is theoretically accommodated but there is only one size fits all participation. Sit up, stay engaged at the table and maybe, if you are determined, manage 8 hours of sleep. Day one, I functioned. Day two, I functioned. Day three, I functioned and I stopped holding my breath waiting for a glitch as my body rebelled. For five full days I functioned just like any other member of the working world. And I loved it. Luckily, I was able to manage quality food and exercise (there was no day that I walked less than five miles – god bless Manhattan.)

The formal meeting ended. I switched to family housing, slept a full 10 hours and had enormous support in the logistics of the second adventure. I awoke at a leisurely pace on Thursday to walk the 3 miles to Penn Station, train to Philly and exit the train to find the one and only Holly Pruett waiting at the top of the escalators prepared to snap a photo to document this moment – after 18 months we were going to walk to University of Pennsylvania in Philly for a medical appointment. We were finally here.

Holly apologized for her ‘wardrobe malfunction’ but I knew she was the perfectly attired companion for my assignment today to prove to UPenn that I am in ideal health. Holly looked young, fashionable and vital, loaning a definite edge to my efforts. She had clearly spent her proceeding 10 hours in Philly preparing to be a tour guide as we walked the mile from the train station to UPenn. If this was to be my new home, I should start learning about it. (Philly is the 5th largest US city, has five major sports teams and a superstitious relationship with where William Penn’s statue resides in the relative height of downtown Philly. There is more, much more, but we hope to have time to share the delights of Philly.)

In no time we were at the stunningly new, open design of the research wing, signed in and waiting for our appointment to start. Both Holly and I sighed with enormous relief when they acted like “yes, we are expecting you.” All the intake folks were like “really, you are traveling here from Oregon?” YES! WE ARE!!!!!!

The person we have negotiated with for 18 months was there in the flesh and blood. Everything started with hugs. The repeating of information, often having a flash of panic, ‘wait, could sharing this disqualify me?’ Meeting the doctor in charge, Dr Tanyi, who like my new OHSU doctor, is both brilliant and communicating to me through a Slavic accent that I have yet to master. With great energy he reviewed the theory behind the TWO (who knew) clinical trials that I was being screened for. Between needing to remind myself ‘I am truly sitting here’ and the accent, even with my great familiarity with the trial theory I know I missed details.

After the physical exam, he declared me an ‘optimal candidate’, posed for a group photo and left us to meet the project lead and work out the details like the dates for my formal signing of paperwork (May 8th), apheresis/dialysis (May 22nd) and the first vaccines over the three days of June 4th, 5th and 6th with subsequent vaccines every three weeks thereafter until I decide to stop, we run out of my tumor or the cancer grows.

I arrived home after midnight last night. I am thrilled to be home and ever hopeful that by choosing to loan my body to the frontier of medical research forward steps will be made in taming ovarian cancer and extending my own life. Formal signing of paperwork will not happen until May 8th but there is every reason to belief that, courtesy of many, I will be enrolled in the Phase One, cohort four arm of this trial. Let’s keep our fingers crossed for just a little longer.

What a week! Thank you all for the great send off.

love, marcy

 

From Plodding to Zeal

Monday, March 25th was my actual birthday and what a lovely day it was. Quite simple and easy, but with the addition of warm and sunny weather, MARVELOUS! Thank you for all the varied greetings.

Since energy is a big challenge these days and because I am determined to dance at Saturday’s dance party, I am trying to do very, very little this week. (Plus, I fly off to the east coast early Monday morning which demands even more caution in my current schedule as travel is exhausting.)

Three years ago my chest cavity was filling with migrating cancerous fluids collapsing my lung. April 4th 2010 I could barely walk into the ER my breathing was so limited. This April 4th my assignment is to prove just how fit I stay despite three years of cancer treatments as we convince the UPenn docs to accept me into their competitive trial.

Three years later we are still celebrating the marvels of being alive while accepting how tenuous it can be. It is perfect that Saturday’s party is both a hello, as I connect with friends from varying stages of my life, and a goodbye sendoff as I get ready to start my east coast adventure in extending my life.

Thank you everyone for contributing to my still being alive on this glorious planet.

1st Press Release on *My* UPenn Trial

Only for those who like details. This gives you a sense of why it has taken me 15 months to get this close to being admitted. Everyone wants in because of their reputation on being on the front lines of extending lives of cancer patients.

warmly, marcy

Two-Step Immunotherapy Attacks Advanced Ovarian Cancer, Penn Medicine Researchers ReportPersonalized Vaccine Made from Patients’ Own Tumors Spurs Immune System

PHILADELPHIA — Most ovarian cancer patients are diagnosed with late stage disease that is unresponsive to existing therapies. In a new study, researchers from the Perelman School of Medicine at the University of Pennsylvania School of Medicine show that a two-step personalized immunotherapy treatment — a dendritic cell vaccine using patients’ own tumor followed by adoptive T cell therapy — triggers anti-tumor immune responses in these type of patients. Four of the six patients treated in the trial responded to the therapy, the investigators report this month in OncoImmunology.

“What we proved in this study is that this is a safe treatment strategy,” says co-first author Lana Kandalaft, PharmD, MTR, PhD, research assistant professor of Obstetrics and Gynecology and director of clinical development in the Ovarian Cancer Research Center. “It is a walk in the park for patients, especially compared to standard chemotherapies and surgical treatments for ovarian cancer – literally, some patients left the clinic and went for a walk in a nearby park after their treatment.”

The findings follow research by the study’s senior author, George Coukos, MD, PhD, director of the Ovarian Cancer Research Center at Penn, who showed in 2003 that women whose ovarian tumors were infiltrated by healthy immune cells, called T cells, tended to live longer than women whose tumors were devoid of T cells. That observation and other subsequent ones suggest the patient’s immune system is trying to fight off the disease but can’t quite muster the strength to beat it. Therefore, investigators have been trying to find ways using patients’ own tumor cells to boost the immune system’s power. 

In the current study, Coukos, Kandalaft, co-first author Daniel J. Powell Jr., PhD, research assistant professor of Pathology and Laboratory Medicine, and colleagues treated six women with advanced ovarian cancer in a two-staged immunotherapy protocol in which they utilized a dendritic cell vaccine created from tissue in the patients’ own tumor, which was stored at time of surgery. All of these women’s cancers had progressed on standard of care chemotherapy.

In the first segment of the study, the team prepared an individualized dendritic cell vaccine for each patient. They harvested dendritic cells from each patient using apheresis, the same process volunteers go through when they donate platelets or other blood products such as those collected for stem cell transplants. Kandalaft and colleagues then exposed each patient’s dendritic cells to tumor extract produced from the woman’s own tumor, which teaches the dendritic cells who the enemy is. After this priming, the investigators vaccinated each patient with her own dendritic cells and gave them a combination chemotherapy regimen of bevacizumab and cyclophosphamide. Because dendritic cells are like the generals of the immune system, they then induce other immune cells to take up the fight.

Of the six patients who received the dendritic cell vaccine, four developed an anti-tumor immune response, indicating that the approach was working. One of those patients had no measurable disease at study entry because all of it had been successfully removed during surgery. She remains in remission today, 42 months following vaccine treatment. The other three who had an immune response to the vaccine still had residual disease and went on to the second segment of treatment.

The team harvested T cells from each of these three women. Using a technique developed at Penn, they grew the cells in the laboratory, expanding their numbers exponentially, and then reintroduced them into each patient after she underwent a lymphodepleting chemotherapy regimen. Because the T cells had already been trained by the dendritic cell vaccine to attack the tumor cells, the adoptive T cell transfer amplifies the anti-tumor immune response.

Two of the women showed a restored immune response after the T cell transfer. One of the women continued to have stable disease, whereas the other had a complete response to the therapy.

The researchers say it is too early to say whether this type of therapy will be effective in a large number of ovarian cancer patients, but the early results are promising. First, and foremost, she notes, the two-step approach appears safe and well tolerated by the patients. Additionally, the team saw a correlation in both treatment steps between immune responses and clinical benefit, suggesting that it is, in fact, the immune response that is holding the disease in check.

With these encouraging results in hand, the team has opened a larger trial in which they have already enrolled about 25 women and aim for up to 30 more. The new protocol uses an improved vaccine platform and an optimized adoptive T cell transfer protocol. The PI of this study is Janos Tanyi, MD, PhD.

“Large clinical trials have shown that intensifying chemotherapy doesn’t improve outcomes for women with advanced ovarian cancer,” Coukos says. “So we need to explore other avenues. We think the combinatorial approach of both immune and chemotherapy is the way to go.”

Other co-authors from Penn include Cheryl L. Chiang, Janos Tanyi, Sarah Kim, Kathy Montone, Rosemarie Mick, Bruce L. Levine, Drew A. Torigian, and Carl H. June. Co-author Marnix Bosch is from Northwest Biotherapeutics in Bethesda, MD.

This study was supported by National Cancer Institute Ovarian SPORE grant P01-CA83638, National Institution of Health R01FD003520-02, and the Ovarian Cancer Immunotherapy Initiative.

###

Penn Medicine is one of the world’s leading academic medical centers, dedicated to the related missions of medical education, biomedical research, and excellence in patient care. Penn Medicine consists of the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania (founded in 1765 as the nation’s first medical school) and the University of Pennsylvania Health System, which together form a $4.3 billion enterprise.

The Perelman School of Medicine is currently ranked #2 in U.S. News & World Report’s survey of research-oriented medical schools. The School is consistently among the nation’s top recipients of funding from the National Institutes of Health, with $479.3 million awarded in the 2011 fiscal year.

The University of Pennsylvania Health System’s patient care facilities include: The Hospital of the University of Pennsylvania — recognized as one of the nation’s top “Honor Roll” hospitals by U.S. News & World Report; Penn Presbyterian Medical Center; and Pennsylvania Hospital — the nation’s first hospital, founded in 1751. Penn Medicine also includes additional patient care facilities and services throughout the Philadelphia region.

Penn Medicine is committed to improving lives and health through a variety of community-based programs and activities. In fiscal year 2011, Penn Medicine provided $854 million to benefit our community.

 

Updates

Thanks for bearing with me during the very hard months of August and September. I must say that my October, which kicked off with surgery, has been great! Being back in the embrace of treatment allows me to decide that my cancer is being disappeared. My next internal scan could have been as early as now but it is now scheduled for late December/early January and that thrills me. My costume for Halloween will be that of a woman without cancer. (Oddly enough, that looks just like me! Note photo above where both Holly and I are in costume.)

Updates:

Melting Matilda, my remaining tumor being named Matilda, (to the tune of Waltzing Matilda) is my current theme song.

My extracted tumor qualified for UPenn by having more than 100 million cells. It took a full year to get to this place! The next steps start in January with the scan and then a trip to Philly (anyone have frequent flyer miles they are desperate to get rid of?) I would sign paperwork that day *if* my cancer is stable and shrunk and I pass other modest tests. Then two weeks later I would be back for a rather invasive process that harvests dendritic cells from my white cells through a dialysis like machine to allow final production of the Marcy Westerling Vaccine. Two weeks to a month later I am back for the first vaccine treatment! I would have a minimum of 5 trips to Philadelphia so you can see why the donated miles will help. I am also checking out free rides in corporate jets for cancer patients. (I know – too funny.)

My current chemo regime is weekly and low impact but there are also unknowns as I am early in the process and a second drug should get added in next week. Will I lose my hair? Place your bet – half the providers say yes, half say no.

My transition from Kaiser to OHSU should happen this week. Honestly, I still do not know if it will happen. Tuesday or Wednesday I will make the final call to see if the incredibly cumbersome process of getting accepted by a prescription drug plan is complete. (For some reason they could not check the right box that allows an under 65 year old to transition plans in their entry window. Medicare can inform me that they messed up the submitted form but since medicare cant talk to them or vice versa – dont ask me why – being right has little value. So I reapply and again they dont check the right box. Really! Since I have a November 1st intake appointment at my new provider and need chemo election day a resolution happens this week be it Kaiser or OHSU. No call today so I am hoping that they finally found and checked the right little box.

Many of you have been very generous with care packages of late. You got me through a hard time. Now you can save them for the next hard moment of testing. I truly pray that after 15 months of recurrence treatment w.mainly bad news we get a little break in the clouds – disease reduction and clearance for the Hail Mary pass to kick off 2013! (And decent election results….)

And lastly, for those in driving distance to Portland I am doing a reading at a local coffeehouse on Thursday, November 15th from 6:30-7:00.

Marcy Westerling will read from her works on Livingly Dying, a phrase borrowed from the late Christopher Hitchens.

While the content may not seem like date night material, it will be an honest chance to walk with one woman as she faces a terminal cancer diagnosis – including the positives of having a husband and community that walk every step with her.  Cancer is epidemic and dying is a given for all who enter this world.  Why not look behind the curtain for 30 minutes?

They have seating for 50 so please spread the word!

Rain or Shine Coffee House is a bright, cozy space at the foot of Mt. Tabor. 5941 SE Division St -
Portland, OR 97206

A Second Abdominal Surgery – Done

Surgery is never fun but once done it seems much more tolerable than anticipating the process.  I hope to never repeat my 36 hours purge and fast, even though my superstitious mind sees the process as core to me having an easier surgery then was ever imagined.

My famous surgeon who has bludgeoned us with more truth then we have ever requested this past year, usually repeated in 20 minute monologues, seems suddenly delighted.  My current theory is that he so loves saving women’s lives (his reputation) that his churlish attitude towards me represented his resentment that his skills could not master my situation.  And to cope he needed to re-explain that reality.  Now he seems to be stalking me with cheer although he has made no future oriented pronouncements and we all know that my diagnosis stays the same.  (I am not curable.  I never was curable.  But many incurable, terminally ill people live a long time.  I would like to be one of them.)

I am home, happy and feel like I was in one hell of a bar room brawl.  I do wish that I could share the great bruising pattern that even descends my upper thighs – just what were they doing in that operating room!?!

Despite bruises and lacerations, I am clearly in good shape for the scheduled return to chemo today.  It is low dose taxol/avistan, weekly, and considered easy to tolerate.

I am not a big fan of my last year – I appreciate having had the year but I would rather not redo my approach to it.  I never imagined being a chemo failure and thus was so ‘shocked’ by each spiral of bad news.  I feel like I am starting over.  I approach this next year knowing I may never leave treatment, that the quality of my life can be high while in treatment and it is time to end the suspended animation of this past year.  I love life and I can love it while in treatment. What’s more, I intend to more fully live it while in treatment.

Regarding the surgical findings.  The extracted tumor is at UPenn being tested for cell volume as I type.  I will know how it is rated for vaccine use in the next few weeks.  Other tumor material is off to the Clearity Foundation where they will assay it in dozens of ways to see what treatment approaches might best match the current profile of my cancer.  (Cancer mutates constantly.) Next steps with UPenn stay complicated and externally dictated.  It is a longer shot than we would like that I will get in to one of the dozen slots but we are making the best effort possible.  Regardless, I wont be starting there until my current course of chemo is well underway e.g. winter.

My biggest fear counting down to surgery was what would be revealed when they went inside.  We all know some one diagnosed so late that surgery is cancelled shortly after starting because “There is too much.”  The surgeon found my smaller tumors in the omentum had combined into one 10 cm mass that was easy to remove. He could see his intended target far back in my body, seeming the same walnut size as the ct scan had communicated. He was happy to not need to take on the risks of removing it as it sat intricately wrapped around the colon.

Less cancer is always good news especially when your official tool is chemo.  The surgeon could see that I was filled with microscopic disease.  And, of course, I continue to have cancer in the lung but given my growing disease volume the decision to both do surgery and the results of surgery are positive.

Courtesy on this extended support community (YOU!) I feel quite ready for this next phase of the journey.  xo

Off to More Surgery & Trials – Hi Ho

It’s been a roller coaster few weeks.  First my ct scan came back with new signs of disease progression on August 14th.  I have had a year of these dour ct scans now but each additional period of disease growth has worse implications.  My oncologist closed our August meeting by recommending that we pursue our top choice (and only choice) clinical trial at UPenn for a vaccine made from my own cells.  We had been working on qualifying me for this since last November but it is a Phase 1 trial (riskier and thus harder to get into but you are also guaranteed the treatment being tested.)  And surgery is required.  We had been turned down from surgery as an option last November based on little likelihood of gathering enough vaccine material and too much risk.  The current thinking is that you do not do repeat surgery on patients like me who recurred fast and have multiple cancer sites.  Anecdotally, all the women I know who have significantly outlived their prognosis have been multiply de-bulked (eg surgery), many over 5 times.  I was all in favor of surgery under any terms.  What we did not expect was our surgeon also to agree to the surgery that he denied in November.  He said that a tumor was now ‘easily harvestable’ and of clear size to meet the study criteria.  He was also painfully clear that he would do no other cancer clean up while inside because of the current wisdom that it is more risky then productive.  But Surgeon Cappuchini, like my oncologist Dr Mashru, agreed that at this point in time proceeding towards this clinical trial made best sense.

Wow – I was suddenly approved for surgery!  I was quite happy (despite Mike having serious doubts.)

But the devil was in the details. A team needed to be lined up to handle the removed live tumor to then head to UPenn for assessment as I continued with next steps for qualifying for their vaccine trial.  In order to get a complicated, fragile kit delivered to Kaiser many people needed to sign off and each one of them balked and sent out alerts.  Who was this to be billed to?  (Which Kaiser research graciously agreed to cover.) Who was responsible?  By then too many people were involved making liability a new issue.  As people needed to sign off formally they were reluctant to be seen as going against current surgical wisdom (no surgery just to qualify me for a trail – regardless that that surgery would also remove my largest and least responsive to chemo tumor.) Everyone said ‘don’t ask me to sign off, ask him’ until we were stuck in an endless loop – a week plus of this.

No one messed up.  Everyone did their job.  Everyone stuck to the letter of the current rules.  Alas, where did that leave me – the fucking patient who is not always served well by these rules.  Only they are protected from liability.  I am stage iv recurrent ovarian cancer.  The only accepted medical option for me is chemotherapy.  I am now medically labeled a ‘chemo failure’.  There are other chemos to try and I will but in 2 1/2 years my body has shown an incredible ability to nurture cancer while on chemotherapy. This is why women like me do not survive 5 years.

I would prefer a medical system with some waivers that allow informed patients to proceed.  I have spent nine months understanding why the clinical trial at UPenn is my best current hope.  My medical team agreed after a year of trying other options.  I am not trying to waste precious funds or resources.  By participating in trails I use my body as a foil for other women while hoping to buy time for myself.  Alas, this route pursued with tremendous hours, heart and research was denied me yesterday morning.  It seemed final.  We were done pushing.  And then, a wacky phone call came in to set me up for surgery next Tuesday, September 18th.  The surgeon had chosen to take on liability.  I have cursed this surgeon many a time for his gruff bedside manner in which he overly details why I am the rare woman he cannot save.  I have heard him deliver this 20 minute spiel three times now.  It is a bummer to listen to.  But he signed off on the surgery that we had finally hit a dead end on.  Thank you, Dr Fabio Cappuchini.

I have been off chemo for more then a month to allow my body a break, time to get a tooth extracted and now this abdominal surgery. Surgery should happen next Tuesday. We wont know until after surgery how involved it ends up being.  They will start laproscopically (blowing my belly up to the size of a woman carrying full term triplets) but they believe that they will probably have to convert to an abdominal open due to the positioning (deep inside) of the target tumor and its size.  The abdominal open will require more time in the hospital and complete rest but either option keeps me needing to recover much of the next month but hopefully I will return to my new chemo regime of weekly taxol plus avistan by late September.

It’s been a messy, stressful month.  To top it off my letter welcoming to Medicare got ‘lost’ and I officially started September 1st when I had understood it as October 1st – this matters a great deal when you are negotiating tricky surgery. And looking at needing to close out your 25 year health care through Kaiser Permanente (a secret) and navigate the new options via Medicare and pulling together a brand new team….maybe that fun saga will get detailed another time.

Throughout this month an incredible and expanded team of volunteers were tasked in working groups to assist with different levels of negotiations.  A shout out to each and every one of you.

The amazing result is that after 9 months of trying to position me for the best best clinical trial nationally if not internationally I am having surgery to move me forward in to acceptance at the UPenn research scene.  This is less a magic wand then a hail mary pass. But I truly believe that as we now try to get me past the very dicey 5 year survival mark (having past the 90% chance that I would not make it two years!), we have just inched me to a position of actual confidence in the possibility that we will have a big old 5 year survival party in April of 2015.  You, of course, are invited!  Thanks for cheering me on.  much love, marcy

Not What I Wanted…New Scan Results

Well, it’s my 3rd ct scan in a row with lousy news.  I have new cancer growth after 5 months of chemo.  19 chemo doses and the cancer is growing.  It’s enough to give a girl doubts.

So, I will get another port installed asap with great hopes that the surgery works this time because the veins are done.

And then I will start on the imported doxil that I should have gone on 6 months ago were it available.

My bone marrow is very tired but my body continues to function fairly well.  I biked the hour each way to get my dour news.

And my great ‘research’ team abandoned their personal plans for last night to huddle instead over strategies to get my prior clinical trial unblinded and leave me eligible for a new clinical trial out of Pennsylvania.

And that’s enough to give a girl the sliver of hope she needs to keep on keepin’ on.

Enjoy the now because it is real.

xo  marcy

p.s.  The photo attempts to show a work I made at a death and dying workshop last summer.  You may or may not be able to tell that the turtle is literally 1/8th off the work and leaving the lovely nature scene.  I was trying to create the sense of moving forwards, regardless, to inspire me when it all seems a bit much. (Of course, the turtle and I both know that she is headed to an even better beach.)

Testing 1, 2, 3…..

Despite my  intent to write a caringbridge update in December then January, it has stayed a task I avoided as I wondered both “what to say? and “do I have to?” Thoughts I tend to have when I actually have few thoughts. But I know that many of you wonder if my bags are packed for Philadelphia. They are not quite yet.

2012 was a tough year in my treatment experience, largely because I never believed my treatments could be so unsuccessful. (I can state that “I am terminally ill with a hard to tame disease”, but that does not mean that I really accept it myself.) I went from one unsuccessful treatment approach to another as some tumors responded but new tumors grew. By the summer I was on a chemo that actually burned my butt, feet and hands – very surreal. You accept it in the moment because it is the reality but when you look back it’s like, “Wow. Really?”

My current treatment is considered easy to tolerate and it is. I expected to ‘graduate’ in December and was surprised then demoralized when the retrospectively obvious was stated for the first time – I should stay on this chemo for the complete 6-8 cycles (eg months) if it might be working.

This delays my start at UPenn. And the easy to tolerate chemo routine becomes less easy to tolerate as the effects are cumulative.  I find it harder to breathe when active, always unnerving. (The doctor says my lungs are not filling w.fluid – very good news.) Breathing hard after walking is just another side effect of treatment. The other morning when I biked to chemo, parked and got on the elevator with a security guard, I could see his concern at my heaving breathes. I hate that. It took almost 10 minutes to settle down so that I could talk. The same thing happened yesterday when I walked to a store. All Fall I tracked my hair loss to see if my thinning process would, in fact, lead to baldness. I felt triumphant as I still looked ‘normal’ in December but can I stall the effects of my hair loss for an entire 6 months? (You may wonder why would I even care. Well, I care.) Then there is the start of neuropathy in the fingers and toes.

I know the escalating breathlessness will disappear post chemo but neuropathy tends to stay a permanent companion. I accept these side effects of trying to stay alive, each of us has a similar list of barriers and struggles, but in the weeks leading up to a scan (vs the great cancer vacations of months like October and November) I find myself less patient with the equation. “All this and I’ll probably still fail my ct scan!” Such thinking happens. For those of you positive-thinking-all-the-time folks, please know that I have assumed the best when having most of my other ct scans and gotten walloped with bad news, so honestly, I dont think I am growing my tumors by wondering just what all my chemo distress is accomplishing. I have even added in two days fasting before and after each weekly infusion since early research shows it can reduce side effects and may amplify the chemo focus on the cancer cells – I am working hard to tamp down my tumors.

The delay frustrated me. It continues to frustrate me because I have no desire to spend my summer months traveling back and forth to Philly. This timeline should have been fairly obvious at the outset but communication and leadership is all the more challenging when you change providers and have a long distance trial you are trying to accommodate. Mainly I stay frustrated that so much of my life is about staying alive and the suspended state it requires. I vowed to find my footing in 2013, reclaim my life but building a life beyond the constants of daily health care regimes is just not that easy for me. I have only so much energy. I have only so much vision.

I have deemed myself in a malaise and thus exempted from much more then putting one foot in front of the other this December and January. But you wonder and ask what is going on with UPenn, which I appreciate. I will be scanned in late January with results on the last day of the month. Because my blood work is not an indicator of what is going on inside me, this will be the first real check-in since early August. If it shows no new tumor growth, I will stay on the taxol/avistan combo through mid-March or possibly early May. At that point, if declared by my doctor to have had an ‘optimal response’, I will then transition to the UPenn trial. UPenn requires seven visits to Philadelphia in a tight numerical sequence. (And forget about that corporate jets transportation.) I am still not ‘in’ the trial until I physically go there, get approved and sign the paperwork. Until then my slot can go to the next candidate but as I have worked for 18 months to qualify so has every other candidate faced these barriers. While it has been tempting at times to give up on this trial, my heavily treated body is no longer eligible for most trials. And UPenn stays a dynamic place for cancer break-throughs.

In the meantime, I stay distracted with the endless paperwork of being alive. And I scheme (thus far unsuccessfully) about a winter trip to somewhere warm and sunny. Or just warm.

Malaise – it’s a lovely word that hits the spot even when you are not quite sure what it means. It is “a general feeling of discomfort, illness or uneasiness whose exact cause is difficult to identify.” Okay, i probably dont qualify for the latter part of the description but I still claim the malaise of December and January and do not see it as a negative thing. I had lovely holidays. I enter 2013 with hope. And that sense of malaise that sits with me like my knitting, well, I think it is just fine for now.

Thanks you as always for the many kindnesses that keep this journey just fine for Mike and me.

warmly, marcy