Good teachers are exhausted the last few weeks of the school year. Athletes talk about leaving it all on the field. Teachers leave more than that in the classroom. For 10 months, every waking moment is about the students sitting in front of you for six hours a day. Your nights and weekends are not your own. They are burned up grading and commenting on student work–and on preparing the next day’s slate of lessons.
Of course, I may be entirely wrong.
Six years ago, Jane and I were coming to the end of what had been our most difficult year teaching. Jane was hit hard by the H1N1 flu in October and had developed pneumonia in the midst of that struggle. She missed nearly a month of work and had tried to find creative ways to get her students caught up–especially those in AP.
Lessons of a Winter’s Tale
In February, she started having swollen feet at the end of the day. Each night as she worked on grading papers and I reread the novels I was teaching, I would massage her feet to try to ease the swelling and the pain she was experiencing. Jane spent every day on her feet on a hard floor. Her feet had always hurt. The swelling just seemed a new addition to the aches.
Your nights and weekends are not your own.
But the swelling got worse and crept up her shins to her knees as the spring arrived. She was having trouble with the stairs in the building. Sometimes, she admitted later, she seemed to be talking to her students from a great distance. I tried to get her to see her doctor–but she worried about missing more time with the AP exam looming.
The death of spring
We went for a walk one afternoon. It was something we did after dinner as the weather warmed. We were coming up a slight incline and Jane suddenly said she needed to sit down. She eased herself onto the curb. We thought she simply hadn’t fully recovered from the illnesses that had fallen on her that fall. In a few minutes, she felt fine and we continued the walk.
Sixty-six months ago–five-and-one-half years ago–today, our closest friends gathered in her hospital room with me to bear witness to her passing. I was strong that day. I read to her, recited poems, said our prayers for the dying and the dead. We talked about the woman she was and how she had led her life. And then she was gone.
…Jane’s heart was the problem.
I stayed strong through the calls to relatives and friends; stayed strong on the ride home and through the public events of the days that followed–the wake, the funeral, the repast, the small gathering afterward. Inside, I was as shattered as a human being can be. But no one saw that. I cried when I was alone, screamed when I was alone, mourned when I was alone.
Lessons in avoiding addiction
I went back to work two days after the funeral. Our students had lost their mother. I would not let them lose their father as well. But I was not right in the head. I’d read a paper three times before it made sense–and I ‘d know the problem was not the writer, but me. I remember almost nothing about the last six months of my teaching career. I’d like to say I was drunk–but I was stone-cold sober. Addiction runs in my family, and I knew if I started drinking I would never stop.
…I was as shattered as a human being can be.
Maybe I should have.
Lessons from my addiction
Instead, I went to war against NET cancer. I wrote pamphlets and did fundraisers. I talked to doctors and nurses and reporters and ordinary people. There were times I reminded myself of Coleridge’s “Ancient Mariner,” condemned to recite his sad tale over and over again to the ears of people who had other things to do with their lives than listen to me talk about the tragedy of mine.
…I was not right in the head.
I could do nothing for Jane. NET cancer had snuck up on her–snuck up on us both–and sucked the life out of her like an aphid on a leaf. I’d failed her–some would say I was meant to–but if I could find a way, it would not happen to anyone else. Awareness? I’d been in the awareness business for years. Fundraising? Not my long suit, but I’d learn. As one of my students said to another, “If I were NET cancer, I’d be afraid–I’d be very afraid.”
Nothing to fear
That confidence was grossly overrated. We’ve made progress against NET cancer, both in terms of science and in terms of awareness since Jane’s death. But I’ve had very little to do with either. I do what I can, but my friends are not rich and I don’t have anything that looks remotely like Bernie Sanders’ mailing list. Local newspapers give me space periodically, but I still have not figured out how to get the major media outlets to pay attention.
“If I were NET cancer, I’d be afraid–I’d be very afraid.”
My supposed strength is an illusion. Sixty-six months after Jane died, I am still deeply in mourning. It’s hard to make headway when part of every month vanishes in a miasma of guilt–I should have saved her–and mental and emotional paralysis. I crawl into bed too often wondering where the day went and how nothing on the to-do list got finished–or even started.
Fear itself
I’ve no idea where these sixty-six months have gone. Large chunks of the first three years simply don’t exist in my memory. I go back and read some of what I’ve written here and elsewhere to discover who I was pretending to be at the time. The only thing I know with certainty is that everything hurt like hell every day–and that I worked really hard to create the illusion that it didn’t.
My supposed strength is an illusion.
And I know I am still not quite right in the head. There are still boxes of Jane’s things I keep making excuses not to open or give away; boxes of mugs we bought together I’ll never use again but can’t bring myself to part with. I bought new furniture for the living room nearly a year ago. The old stuff is still in the basement, waiting for me to find someone who wants it.
Discovering lessons at home
And sometime in the last month or so, I’ve realized I spend an enormous amount of time in the living room–the one room I’ve redone nearly completely since Jane’s death. I still sleep in the bed we bought when we got married, surrounded by the rest of that bedroom set. Yes, I moved it into a different room and repainted the walls, but it is still as though Jane never died.
…I am still not quite right in the head.
And other than changing the orientation of the dining room table, the dining room is almost exactly as she left it. I eat in the kitchen, except when I have major company. I am not comfortable there otherwise. Meanwhile, as I’ve begun to revamp the landscaping in major ways, I find myself increasingly making excuses to sit outside, even when it is cooler than I’d like.
Lessons on moving forward
Two days ago, I did what I likely should have done shortly after Jane died: I ordered a new bedroom set and a new dining room table that reflects who I am rather than who we were. I spent most of the last two days going through the bedroom and the study, cleaning out closets and drawers and making decisions about what needs to stay and what needs to go–and marveling at some of the things I’d set aside as too emotional to part with four years ago. I mean, empty candy tins? Really?
I still sleep in the bed we bought…
Jane didn’t want me turning the house into a shrine of memories about her. I promised her I wouldn’t do that. The last few weeks, however, I’ve realized that is exactly what I’ve done in too many ways. I wonder now if while trying to be strong–sleeping in our bed, sitting in our chairs, working at our table–they are, after all, just objects–I wasn’t undermining my own healing. We become emotionally attached to things to begin with; when those things are attached psychologically to a person we have deep feelings about, that emotional attachment to those things grows even stronger.
Lessons ahead
Of course, I may be entirely wrong. I’m still in love with Jane. We built this house together–and no matter what changes I make to it, that will remain the case. My mind may be irreparably damaged and all of this no more than rearranging the deck chairs on the Titanic.
I mean, empty candy tins? Really?
But I’ve taken the plunge. For the next several weeks I’ll be flying through the air while I await the new furniture and continue the landscaping projects. The water may prove too cold, too hot or just right. It doesn’t matter. I’m committed.
And, in the meantime if you know anyone local who’d like a used bedroom, dining room table and chairs, or couch and love seat…
My landscaping project has uncovered a number of lessons–and not all of them have to do with paths and garden beds. The most important lesson may be that changing the environment may change the pattern of ones grief.
In Tennessee Williams Cat on a Hot Tin Roof, Brick talks about waiting for the click–the point at which all the pain drains away and everything seems all right. He gets there by consuming large quantities of alcohol. I don’t drink very much or very often–and even less so the last six weeks. But, like Brick, I am waiting for the click.
…I haven’t done it as well as I could.
I’ve been waiting for it for 63 months now. I’ve tried losing myself in work, in films, in books, in research; I’ve tried meditation, grief groups, and therapy. Increasingly, I begin to feel my father had it right the night Jane died: there is nothing anyone can say that will make any of this feel any better. In truth, there is nothing anyone–including me, apparently–can do to make the hurt go away.
The click in my head
Yes, it is less paralyzing most of time than it was at the beginning. Lose an arm or a leg and you will learn to cope over time. It does not bring the limb back–you always miss it–but you do figure out a series of workarounds that enable you to look normal from the outside a good percentage of the time. But you know it isn’t the same even if the world can forget.
…my father had it right…
I keep hoping, though–foolish as that is. In December, I passed the five-year mark since Jane’s death. I thought that would be the moment of the click in my head–at least that was what a part of me wanted to believe. I resolved to cut back on my visits to her grave; I resolved to at least think about dating again; I resolved to do more things that would make me happy.
Death has murdered sleep
I’d been there several times before. I believed the nonsense about the first year–what the grief community calls “The Year of Firsts“–being the hardest. The second year was much harder than the first because–no matter how hard you try to believe the second year will be better, the person you loved is gone and not coming back except in your dreams–and when you wake up it is so bad that you don’t want to go back to sleep again.
I keep hoping, though–foolish as that is.
You start putting off going to bed at night because you can’t handle the dreams–no matter how happy they make you feel when you are in them. You gradually come to see them as you see drugs–a temporary escape that makes things worse when you come down from them. But lack of sleep carries its own consequences. The depression simply increases from another angle.
Everything comes with a price
I knew better than to expect much from the second anniversary of Jane’s death. But I had hopes for the third–and for the 25th anniversary of our marriage–and, most recently, for the fifth anniversary of her death. There is no magic bullet for grief, though.
…you don’t want to go back to sleep again.
Intellectually, I know that. I know taking her pictures out of the main living areas was a good thing. I know emptying her suitcase last week was a good thing. I know slowly redesigning the yard and the rooms of the house is a good thing. But each comes with an immediate and crippling emotional price–just as each date on the calendar does.
Why, this is Hell…
Much of January and February of this year were dead months. I had trouble getting up, trouble writing, trouble thinking, trouble getting anything done. They were the price of my expectations of what that fifth anniversary would mean. There was no click and my mind descended into the Hell of its own making.
Intellectually, I know that.
Hell is a place of pain without hope of an ending made worse by the illusion that things will get better. Sometimes, I live there. But I am also the ghost of Jacob Marley. I can do nothing about my own pain–but perhaps I can find some way to ease the spirits of the other damned souls; perhaps I can find a way to prevent–or at least delay–others from joining me here.
Fighting destiny
In my head, I know it is a foolish idea. I know that at least half the population is destined to lose someone they care about; that half of us will be widows or widowers no matter what I do. I cannot stop death. I can only help to slow it down, at best. In the cosmic scale, it amounts to nothing.
There was no click…
But my heart sees the mother with her children, the husband with his wife, the child with her parents. We do not live on a cosmic scale–we live within the construct of our short lives in these fragile bodies. People will tell you these bodies are but vehicles or vessels for souls. I will tell you the same thing.
Body and soul
But in this world we inhabit our bodies matter every bit as much to us as our souls to us. This life is the one that matters now–and it may be the only thing that actually does. Jane’s soul my flit about the house, but I cannot hold it in my arms or feel its breath in my ear. Absent that, she has likely better things to do than hang around waiting for me.
We do not live on a cosmic scale…
And I have better things to do than lying in bed mourning for things that are gone and cannot be recalled in any meaningful way. Jane and I lived to ease the suffering of others, to offer a hand up out of ignorance and poverty, and to bring some small modicum of joy and hope to those who need it.
Waiting for Godot?
For 63 months, I’ve tried to keep doing that. My disappointment is I haven’t done it as well as I could. But, like the person who has lost an arm, or more, perhaps I need to work harder on the workarounds and stop waiting for the click.
…I have better things to do…
We live by living–and not by waiting.
A plant grows by living. It may pause now and again–waiting for the click that tells it growth is possible again–but it never really stops doing what it does to survive.
I’ve spent a good chunk of my life involved in journalism. That fact has made me a pessimistic-optimist or an optimistic-pessimist, depending on the day of the week. When I look at anything, I see a mixture of the good and the bad. I tend, however, to look at failures before looking at anything that looks like an accomplishment. That is especially true when I look at what I’ve done.
We’ve done a lot to raise awareness…
So in my last post, I looked at where I’ve fallen short of what I proposed to myself five years ago. But I have to be realistic: Walking with Jane has put down a pretty firm foundation in all three of the areas I discussed there. We may have fallen short of the goals I set, but we have created a structure that may yet reach those goals.
Accomplishment 1: Walking with Jane
First, five years ago, Walking with Jane did not exist beyond a vague idea I sketched out on paper. I had no idea what was involved in setting up a non-profit. If I had, perhaps I would have thrown in with an organization that already existed. But my vision is very different from most and I don’t always play nicely with others when I’m trying to do something I perceive as important.
…I have to be realistic…
I don’t like asking if I can do something. Even small-scale bureaucracies make me crazy. I like the fact I can make a decision today and start making it happen tomorrow. Walking with Jane gives me that ability.
Weighing priorities
And yet, as recently as this month I seriously thought about closing up this shop so that I could focus entirely on 3-in-3: The Campaign to Cure NET Cancer, the new fundraising drive for the Program in Neuroendocrine and Carcinoid Tumors at the Dana-Farber Cancer Institute. The leadership there talked me out of it because they seem to see a need for Walking with Jane as a separate entity from DFCI.
…I don’t always play nicely with others…
But the more I thought about it, the more I saw that need as a real thing. DFCI is not a small organization and that makes it less nimble. I can write about breaking news or fundraising events without going through multiple offices to get approval to do it. I can decide to do a fundraiser two months from now without going through any channels beyond my own mind.
Building on the accomplishment
There are problems with being a stand-alone organization, of course. The paperwork I face in the next few weeks between preparing for our annual board meeting and filling out the forms for the state and federal governments consumes a great deal of time and energy–as does the record-keeping after each fundraiser. And when things fail–and they do–I have no one to blame but myself.
…I seriously thought about closing up this shop…
But those problems are the price we pay for being able to turn on a dime when we need to. Still, we could do with more help–especially when it comes to running events, maintaining the website, doing the writing, the reading, and the 10,000 other things that demand attention every day. We have volunteers, but we can always use more.
Accomplishment 2: Building an image
Walking with Jane provides the structure that makes doing what we do possible. And we’ve worked hard to create a strong image of who we are and what we do. That begins with the name. Initially, someone suggested Walking for Jane–but that wasn’t who Jane was. I tell people she would haunt us for adopting such a name. Jane was more a “with” person–she didn’t like the idea of people doing things “for” her.
…we could do with more help…
The logo that adorns every page of the website, builds further on the idea of Jane’s strength and vision. It is based on a photograph I took of her in the Blue Hills just outside of Boston in the early 1990s. Bonnie Cohen, a former student of both of ours, created the image over the course of several days, working to get it just right. Some graphic artists have called it the most powerful logo they have ever seen.
…we’ve worked hard to create a strong image…
But image means nothing without concrete actions in support of that image. It can underline a message and inspire, but a successful organization needs more than that. It has to have not only a clear vision–but also plans and structures to make that vision a reality.
Accomplishment 3: The pamphlets
Our first step in that direction began even before we had the beginnings of a plan. On my flight to Seattle in December of 2010 the week after Jane’s funeral, I had drafted our first pamphlet, Is it IBS or is it NET Cancer?I sent that draft off to Dr. Jennifer Chan shortly after I got off the plane. By spring, the pamphlet was ready to go to press.
…the most powerful logo they have ever seen.
Jen and I revised that pamphlet for the third time this fall. The new edition goes to press next month, along with our second pamphlet, NET Cancer FAQs, which Jen wrote this fall and which I finished the design work for this month. We previewed that pamphlet at the launch of the 3-in-3 Campaign on December 9.
Accomplishment 4: Social media
From the start, I knew we needed a social media strategy. In 2011, Facebook was already huge. But I had no idea how it worked or how to leverage it to raise either awareness or money. I still have no clue how to do the latter. I’m not sure anyone really does. But raising awareness was another matter entirely once I understood something of how it worked.
…I had drafted our first pamphlet…
I won’t pretend I fully understand how the thing works, but we can get the NET cancer message out to a pretty sizable audience through the combination of my personal page, the Walking with Jane page, and the various support group and interest pages. We’ve expanded to Twitter, tumblr, and Google+ and dabbled in Pinterest and Instagram since 2011. But it is hard to keep up with all of them on a daily–or even weekly–basis when there is only one of me trying to keep all of it in the air.
Accomplishment 5: walkingwithjane.org
Those first efforts on the awareness front were joined September 2, 2011–on what would have been our 22nd anniversary–by the launch of walkingwithjane.org. Carissa Broadbent‘s elegant design created a striking yet simple design that was easy to navigate as well as maintain, and avoided the clutter too many other websites force on readers. The website creates a place for long-form reporting that does not work well in social media.
…we needed a social media strategy.
The website was far from an instant success. After an initial four months of satisfying numbers, hits on the website went into a steep decline–a decline that eventually had me considering killing the website because it was taking lots of time to maintain with very little apparent impact or interest to show for it. Then, for reasons that remain unclear to me, things took off in April of 2013. We will close 2015 averaging over 2000 hits a month for the year.
Failure and success in November
In November, 2011, we put together a package of stories on NET cancer and made them available to newspapers and magazines across the country. Unfortunately, what we had hoped would be a huge coup caused barely a ripple outside of one local weekly and one local monthly. It was an effort we have not repeated since.
The website was far from an instant success.
Instead, the following November, we launched an 18-hour social media event we called a mediathon for NET Cancer Day on November 10. We posted new information, videos, and stories at about 15 minute intervals on walkingwithjane.org, Facebook, and twitter. The response was solid and we have repeated that effort each year since with steadily improving results.
Accomplishment 7: PSAs and videos
As part of that, we’ve put together a number of public service announcement videos that range in length from 15 seconds to nearly 10 minutes. At one point, we had a script on someone’s desk at CBS. Unfortunately, nothing came of that. And outside of the NET cancer community, the other videos have not found much of an audience.
…we have repeated that effort each year…
Those videos, as well as some other videos we put together, meant we needed someplace people could access them easily. Thus was the Walking with Jane Channel created on YouTube. I’d like it to do more than it does, but again, there are only so many hours in the day.
Accomplishment 8: Local media presence
While we still have not figured out how to reach the national media, local press coverage of Walking with Jane has been outstanding, thanks in part to Phil Devitt, a former student who is a rising star in print media. He now supervises a chain of several small weekly newspapers and has influence with one local daily. We’ve cultivated a relationship with the other local daily which is part of a different chain with a couple other papers in the immediate area.
…we had a script on someone’s desk at CBS.
The upshot is fairly frequent local coverage of what we are doing to fight NET cancer. And every story contains a short section on symptoms of the disease. Fall River and New Bedford may have the most NET aware public in the world as a result.
We’re ready for the next move
We’ve done a lot to raise awareness of NET cancer over the last five years, though we’ve had less impact than I’d like. Still, the structures are in place that make raising awareness in the broader community possible.
The upshot is fairly frequent local coverage…
How we manage that breakout is one of the things the next five-year plan will need to address.
When it comes to raising awareness about NET cancer, I’ll go anywhere and talk to anyone. Last year, I did a series of presentations during a conference for student councils in Massachusetts and addressed a local Women’s Club. That is one accomplishment I neglected to mention in the main article.
Editor’s Note: This is the second part of a series looking back over the first five years of Walking with Jane and our goals for the next five years. The next part will look at our efforts to date to create more resources to support research on NET cancer.
(Editor’s note: This is the text of the speech I gave December 9 at the Dana-Farber Cancer Institute as part of the kick-off for 3-in-3: The Campaign to Cure NET Cancer. The subheads were not included in the speech. They are used here as graphic devices to break up the page.)
I want to welcome all of you to this kick-off of 3-in-3:The Campaign to Cure NET Cancer—a campaign we hope will be a real game-changer for all of you here—and for all NET cancer patients and their families everywhere.
But tonight is a truly bittersweet moment for me. Five years ago tonight I was in a hospital room with my wife. She’d gone into a coma about 10 that morning—a coma induced by her fourth and final carcinoid crisis following surgery to replace the valves in the right side of her heart that her cancer had destroyed.
…a real game-changer…
Just before 6 p.m., Jane regained consciousness for a few minutes. I had to tell her there was nothing more her doctors could do—that we were taking her off the machines that were helping her breathe, taking out the feeding tube, and shutting down her pacemaker so that she could finally die.
“You’re going home to the garden,” I told her. She closed her eyes and I kissed her forehead. “Good night, my warrior princess,” I said. That’s the last thing I know she heard me say. I read to her, I sang to her, I talked to her, and I held her hand—but how much she was aware of after that….
The warrior princess
Jane was a warrior against ignorance all her life. She taught science—as I taught English—in a school that educated the working class children of a small town. We stayed there because we believed they deserved as good an education as anyone else got.
…she could finally die.
And when Jane was diagnosed with NET cancer, she became a warrior against it. She was determined to be the first person to beat it, but she was equally determined to end our ignorance of the disease and how it worked. She faced her life and her death with a singular kind of courage.
She died just before 8 p.m the next night. There was a slight catch in her breath—and she was gone.
Warrior days
Two days after we buried her, I went back to work. I was a teacher—and my students needed me. But Jane and I had decided well before she was diagnosed that we would retire from teaching that June—and I kept that promise.
There was a slight catch in her breath…
But I had made another promise—that if she killed her advanced disease the only way anyone ever had—by dying and taking it with her—that the battle against it would not end for me until it was dead.
I went to Seattle to be with my family that Christmas. On the plane out, I drafted my first NET cancer pamphlet. On the plane home, I drafted my plan for attacking the funding and awareness issues that had made Jane’s death inevitable—and that still plague our efforts today.
Warrior work
On the night of what should have been our retirement dinner, I spoke at the local Relay for Life and walked through the night in Jane’s memory.
But I had made another promise…
That fall, I walked the length of the Boston Marathon course for the first time. I raised nearly $5,000 for NET cancer research—far more than I expected. In December, I pledged $100,000 over five years to support the small but growing program at DFCI. Tonight, I make the final payment on that pledge—and renew that pledge for the next five years.
But I don’t just put my money where my mouth is—I put my labor there as well. I’ve captained four Jimmy Fund Walk teams that have raised an additional $175,000 over the last four years. I’ve put together pamphlets, a website for Walking with Jane that averages nearly 2000 visits a month, and served the NET cancer community in every way I’ve been able to think of—including asking everyone I know for money.
The dream
I do that in the hope that my friend Jillian will see her two four-year-old sons graduate from college and dandle their grandchildren on her knee. I do that in the hope my friend Andrew will have the same experience with his pre-teen daughter. I do that so my friend Kara can dance at her teenage son’s children’s weddings.
…I don’t just put my money where my mouth is…
And I dream of the day I can stand at Jane’s grave and say, “It’s over—it’s dead. No one ever has to go through what you did for 30 years—the insomnia, the stomach pain, the bloating, the diarrhea—NET cancer is well and truly dead—and we played our part.”
I truly hope you will all join with me in making those dreams a reality.
Walking with Jane president Harry Proudfoot cited his wife Jane as a warrior against ignorance both as a teacher and as a NET cancer patient in a speech at the Dana-Farber Cancer Institute, December 9, 2015.
Introduction of Jennifer Chan, MD
Now, it is my honor to introduce Jane’s oncologist, the director of clinical trials for the Program in Neuroendocrine and Carcinoid Tumors, Jennifer Chan, who holds a very special place in my heart.
I can’t speak to Jen’s feelings when she first met Jane. But for Jane, it was as though she were meeting her sister. Jane was a very private person. It took me years to get where Jen was after two minutes.
But Jen is a very special kind of person. Jane was exhausted that night. We were in bed reading at 8:45. Then the phone rang. It was not a telemarketer—it was Jen—and she had a plan.
When Jane was in the hospital, Jen spent part of her lunch break with us seemingly every day. On Thanksgiving, she put the turkey in the oven and came to see us.
And on the last day of Jane’s life, she sat with us—both during her lunch and before she left for the day. She said she saw patients in clinic that day, but her heart was in the room with Jane—and with me.
I could tell you about Jen’s background, her colleges, degrees and accomplishments—but the most important thing I can tell you is she is wonderful, intelligent and creative human being who brings love and passion to whatever she does.
Ladies and gentlemen, my very dear and very good friend, Dr. Jennifer Chan.
(Editor’s note: Please help spread the word on this campaign by sharing this speech and the press release that will follow shortly. When the slides from Jen and Matt’s presentations become available, I will pass those along as well. Contribute to 3-in-3: The Campaign to Cure NET Cancer.)
(Editor’s Note: My apologies for a long gap between posts here. I’ve been busy working with the people at Dana-Farber on a new fundraising campaign to raise money for NET cancer research there.)
Thanksgiving Eve
Thanksgiving five years ago was both the best and worst I’ve ever had. It was the best because, despite a life threatening coma that had ended two days before, Jane was alive and seemingly well. The night before had been difficult. My simple presence in the room seemed to be having a bad effect on Jane’s state of mind–and on her physical health as a result.
…it has to be done.
At about 10 p.m., the medical people sent me down the hall to sleep in another room. “If we need you, we’ll come get you–and if we do, you’ll need to be sharp.” The words were not comforting, but Jane and I had insisted they be brutally honest at all times about Jane’s condition and prognosis.
Thanksgiving sunrise
I slept very little that night. Mostly, I waited for sunrise. I knew, somehow, that if the sun came up and no one had come to get me, things would be all right. And they were.
The words were not comforting…
I called the front desk. They said to come over when I was ready–that things were better. I walked down the hall and turned into her room. Jane was sitting up in the bed. She turned to me and smiled. “I love you hubby.” And then I was in her arms–and we were happy.
The best of times, the worst of times
Friends brought her father and sister to visit that day. When they left, I went downstairs and found a cup of pumpkin soup. By the time I got back, Jane’s chicken broth had arrived. That was our last Thanksgiving dinner together. We watched the Patriots beat the Cowboys and Jane fell asleep. Jane thought this was the final brightening in her family’s tradition. I had hope it was more than that–but we had squeezed out one more Thanksgiving.
…and we were happy.
And that was why it was the worst Thanksgiving–because it was the last. It haunts me to this day. Twenty-four hours later, she had another carcinoid crisis and went into another coma. I spent Saturday morning agonizing over what to do: should I let her go? Was there still a fighting chance?
Decision point
A friend came up that morning and Jennifer Chan, her oncologist, came in a little later. They convinced me that there was one more card to play: a massive dose of octreotide that would run the hospital’s supply to zero and deplete supplies elsewhere in the city as well.
It haunts me to this day.
Six hours later, Jane was awake–and both surprised and delighted to be there. Thanksgiving was not a false renewal after all. She was going to go home–not for Christmas, she knew–but in time for us to spend February vacation in the room overlooking the lake we had spent the last night of our vacation at in August.
The dream–and the nightmare
We lived for that dream for almost two weeks. Doctors put in a pacemaker, friends visited, we watched television together. We even argued once or twice–the kind of arguments people who have been married and love each other have when things are going well.
…one more card to play…
Five years ago today, things started to go to hell. Jane wanted to get out of bed to use the bathroom, wanted me to carry her there. I couldn’t–she had a feeding tube and all kinds of monitors that limited that kind of thing. If she wanted to sit in a chair, she had to be lifted with a small crane.
Into the night
She wanted me too take her home. I told her I couldn’t–not yet. She needed to stay her and get stronger. “I want to go home,” she whispered.
…things started to go to hell.
She did not sleep that night. I should have known then something was wrong. But I was tired. I was cranky. I hadn’t slept in a real bed in nearly three weeks–hadn’t really slept well in months. At least, those are the things I tell myself.
The final crisis
In the morning, the nurses sent me to have breakfast. I brought it back to the room with me as I sometimes did when Jane seemed to want me close at hand. We moved her out of the bed and into a chair. We watched two episodes of Frasier and Jane started nodding off.
She did not sleep that night.
The nurse came in and asked her if she wanted to take a nap. Jane nodded. We put her back to bed and she fell asleep. I sat next to the bed, holding her hand while I read something. An hour went by. The nurse came in with a blood pressure cuff. She said the sensor didn’t seem to be working right. This was not abnormal. Jane’s arms were so thin things didn’t always work right.
The hospitalist
Nurses have great poker faces, but spend enough time with them and you can tell when something isn’t quite right–and we’d asked for honesty. She went to find the hospitalist. He came in and ran through Jane’s vitals. We all knew by the time he was finished that Jane was in a coma. And I knew what that meant.
An hour went by.
He left to call Jen. He came back a few minutes later. “There’s nothing left to try,” he said. ” We promised honesty. We can keep her alive–maybe even bring her out of the coma. But there will be another–and she’ll just keep getting weaker. She’ll never come off the machines again–and we both know she doesn’t want to live that way.”
Keeping promises
The fighting chance had turned into no chance just that quickly. And I knew he was right–this was not how Jane wanted to live. I had promised her I would let her go if–or when–the time came. And I would do it beautifully and with honor.
‘There’s nothing left to try.’
We would start taking her off the machines in the morning, he suggested. That would give me time to gather some friends together to be with us at the end. And if she woke up, I needed to tell her what was going on. It was the hardest thing I’ve ever done–and I don’t think I did it very well.
Building the future
I will give a speech tomorrow night as we launch a fundraising initiative with the people at the Dana-Farber Cancer Institute. I’ll talked about Jane’s final days and hours. I’m not sure I’ll get through it without a cascade of tears. But I’ll do it because, just like letting Jane go, it has to be done.
…I don’t think I did it very well.
It has to be done so that someday there won’t be a need to tell her story again; so that someday no one will have to suffer what she did; so that someday no husband or wife will suffer what I–and so many others–have suffered because of this disease.
May that day come soon.
On Thanksgiving, I gave thanks for what Jane and I had together. But one day I want to be thankful that no one else will die from the cancer she fought.
(Editor’s Note: I will preface this as I did the last post: if death and mourning are not things you want to confront, don’t read what follows. Caregivers will likely find it more useful than patients. I will also say this is not the piece I planned to write this morning. But the memories of Jane in her second crisis refused to leave me alone until I set them down here. Whether they will now let me be or not remains to be seen.)
Breathe with me…
Five years ago Sunday I sat with Jane in her hospital room. She was in the midst of her second post-operative carcinoid crisis–though I did not know it at the time. My normal habit was to meet with her doctors as they did rounds outside her room. But there was something wrong with Jane’s breathing and I didn’t want to leave her.
“They told me you had a fighting chance…”
“Breathe with me and stay with me,” I chanted over and over again as I held her hand. The doctors moved down the hall to the next patient.
Something isn’t right
Six days earlier, during Jane’s first crisis, one of her nurses said to me I was only allowed to panic if she did–and that since she wouldn’t panic, I wouldn’t either. So when there was a catch in Jane’s breathing now, my voice was calm as I called to the doctors and nurses from her bedside, “We need some help. Something isn’t right here.”
I didn’t want to leave her.
The room was filled with people in an instant. They moved me behind a screen so they could work. That’s when my mind came unglued. But I fought it off. I knew I needed a clear head.
The grays in DNR
Jane had a DNR and we both thought that was a pretty black and white thing. But when the came through the screen I was immediately confronted with how many shades of gray exist between life and death.
“We need some help.”
“We know she has a DNR,” he told me. “But we think we know what is going on right now and we think we can fix it. But we have to intubate to buy the time we need to do that. If we’re wrong, we can take the tube out and let her go the way she wants to then.” Simplicity died in those three sentences.
The decision I made
I come back to that moment over and over again. Knowing what I know now, I should have let her go. But I didn’t know any of that. I knew her doctor and knew we both trusted him. I knew Jane and I both believed in the concept of a fighting chance. That seemed to be what I was looking at.
Simplicity died in those three sentences.
I told them to her. I told them to do what they needed to do. I told them if it didn’t work, we’d take the tube out and let her go.
Uncharted waters
Five years ago yesterday morning, Jane was still in a coma. Her breathing and blood pressure were stable. There was an octreotide drip in her arm slowly rolling back the over-supply of serotonin that had generated her collapse. I held her hand and talked to her, not sure she could hear or comprehend any of what I was saying.
I told them to intubate her.
At 10 a.m., I met with her doctors, the nurse on duty when Jane had crashed the day before, and a social worker. We talked about what they thought was going on, about who Jane was and what she would want. The told me they were in uncharted waters in some respects.
What would Jane do?
I thought about Jane, the scientist, as I listened to them talk. I thought about Jane, the compassionate human being, as I listened to them talk. And I thought about Jane, the person, as they talked.
…Jane was still in a coma.
The scientist would want to learn all that she could–help the doctors learn what they could. The compassionate human would want them to learn all they could so the next patient would have an easier time of it. The person would want her dignity.
The backdrop
That dignity had been sorely tried throughout the previous weekend. She had had multiple massive diarrhea episodes that overflowed the bed pan and left her soiled and humiliated. I had been out getting something to eat when the first hit. They would not let me into the ICU until it was cleaned up.
The person would want her dignity.
By the end of the weekend, I was helping change her night-clothes and bedding, holding her on her side as the nurse cleaned and salved her bottom. I remember thinking at one point that I was changing her using the some of the same techniques and dispassion I’d used when I changed the diapers on my younger siblings as a child.
ICU psychosis
The thought made me shudder. I hurt for her every time but carefully kept it out of my voice, face, and manner. I knew where I needed to be–where Jane needed me to be–and knew I could only stay and do those kinds of things as long as I stayed professional in my actions.
That dignity had been sorely tried…
Somewhere in there, Jane lost her mind. There is a thing called ICU psychosis. You can read about it–but reading it and seeing it are two different things. Jane told me the doctors and nurses were trying to kill her, lied to them about how often she was doing her physical therapy–and at times seemed to suspect I was in league with them.
Balancing act
I still don’t know how to balance the things that went through my mind that Tuesday morning. I told the doctors, nurses and social workers about Jane’s vow to be the first person to beat this form of cancer–and my vow to do all I could to help her do that. I forced my emotions down and tried to be logical–to look at the evidence I had and make a decision based on that.
The thought made me shudder.
But there was the voice of the scared little boy in there screaming over and over and over, “Don’t let her die, don’t let her die, don’t let her die…” The voice of reason agreed with the little boy–at least for a few more hours. The doctors and nurses were seeing signs that what they were doing was working. For now, the fighting chance remained–and I would not deny her that chance.
The bedside
Only those who have sat at the bedside of a loved one in a coma understand what those hours are like. There is so little you can do: you hold their hand, you talk to them, you read to them. Periodically, a nurse, doctor, or therapist comes in and you try to stay out of the way while they do what they do. They take blood, listen to the heartbeat or breathing, change a medication bag…
I forced my emotions down…
You know they are doing those things–that sometimes they move you from one side of the bed to the other–but you are aware of nothing but the person on the bed, their unresponsive hand in yours, the steady pulse of their breathing. Sometimes they send you out to get something to eat or to take a walk–but the whole time you are gone your heart and mind never really leave the sickroom.
Waking up
Jane woke up early that evening. She was immediately angry at me because of the tube going down her throat. “Stop,” I said. “They told me you had a fighting chance–and I gave it to you.” She relaxed then and I took her hand. Neither us knew how hard the next 36 hours were going to be, nor how hard the next few weeks would be.
There is so little you can do…
For the next few hours, though, it was peaceful.
Jane still lives in my heart. No month goes by that is not filled with memories of our life together.
(Editor’s Note: Jane’s birthday was on November 17. I have debated since then how broad an audience to send this to–or whether to post it at all. If you are uncomfortable reading about death and mourning, you may want to turn away now and read no further. But if you are a caregiver, what is here may matter to you. If you are a patient, it may help you understand what your partner faces now–and may face later.)
Road trip
Jane would have been 61 today. She would have awakened to cards and flowers and gifts and a poem and breakfast in bed. Later, we would have driven to southern NH to look for Christmas presents and browse the shops. We’d have had lunch in a restaurant we stopped at whenever we were there, then travelled home for a quiet night snuggled on the couch.
If the heart is healed, can the soul be far behind?
Instead, I went to the cemetery where her body is buried this morning. I left some mums there and a card and some tears. I was angry when I left—and sad.
Clearing spaces
Five years is a long time to be in mourning. Five years is no time at all to be in mourning. I’ve lived alone a long time, slept alone a long time, cooked and eaten meals alone a long time.
I was angry when I left—and sad.
This weekend, I started cleaning out the basement. It is where I have stored the things I am not ready to part with. Yesterday, I took the collages of our life together off the walls in the living room and moved them into the guest room. In a few days, I will unpack the suitcase she took with her to the hospital five years ago. It is filled with the clothes she never wore and the clothes she was wearing the day we checked her in for her heart surgery.
A new heart
I don’t know why it is suddenly time to do those things—just that it is.
I’ve lived alone a long time…
Five years ago, we celebrated her birth–and rebirth–in a hospital room in cardiac intensive care. She told the doctors and nurses she had gotten a new heart for her birthday, even though what she really had were two new mechanical valves in the right side of her heart. The plan was for her to move to the step-down unit the next day. She was happier and more upbeat than I had seen her in months.
A different road trip
I should have known…
…we celebrated her birth–and rebirth…
That night, she had her first carcinoid crisis. Her blood oxygen levels fell into the mid 80s, her blood pressure dropped. The doctors and nurses decided she needed a CT scan. But the scanner in the building had closed for the night. The closest one was in a nearby building on the eighth floor. Jane declared she was ready for a road trip—and off they went.
Raised hopes
The scan was inconclusive. Her oxygen numbers came up once she was back on oxygen. Her blood pressure stabilized. I stayed up with her all night and all day the next day. She was weaker than she had been, but she seemed to have turned the corner.
…she had her first carcinoid crisis.
I went back to the hotel and slept for six hours, checked out and moved my car to the hospital. I expected to drive home that night.
Dashed hopes
I did not sleep at home again until after Jane died three weeks later. I barely left her side.
The scan was inconclusive.
Five years later, my heart still bleeds. I get up every morning, I make the bed, eat, do all the necessary things from showering and shopping to reading and writing. Sometimes, as I work on this or that project I can almost forget that Jane no longer breathes, almost forget she is not simply out with her sister.
Small joys–and constant reminders
Then I look up and know she is not there—that her body rests three miles away beneath her family headstone. And then the silence closes in and it is as if she died just moments ago.
I barely left her side.
I debate moving periodically in the hope that some new place will not be so haunting. And then I remember my trips to Seattle since her death, I remember the nights I’ve spent in hotel rooms on one trip or another, I remember being at parties or dinners where the silence comes rolling in—and I know that where I live will not change this grief–that to leave here will only cut me off from the small joys of our life together here—only deepen my grief.
An evolving heart
I remember a friend who lost her father when we were still in junior high school. I remember visiting her home perhaps four years after his death. There may have been some pictures of her father in her mother’s bedroom—or in her own. There were no pictures in the public sections of the house. They did not surround themselves with memories. The house evolved.
…I remember…
Perhaps that is what I am doing this week. Perhaps I am evolving toward some final acceptance that Jane is gone and that my life needs to be about more than her absence—and about something more than the cancer that killed her.
Touching hearts, mending souls
Not that I have not done things other than deal with her death and her cancer over the last five years. But whether working in the garden, reading a novel or a biography, listening to music, or going out to dinner, a play, or just for a cup of coffee with friends, those things are never far from my thoughts.
The house evolved.
Nor will I give up the work against her cancer—I know too many people who have become friends who have NET cancer to walk away from that fight in mid-stream. It will die and I will have a hand—as big a hand as I can manage—in its demise. I owe that not only to Jane and the doctors who worked with her, but to every patient whose life has touched mine in the last five years–and every patient who will touch mine in the years ahead.
The cruelest months
I have no illusions: I will grieve Jane’s death until the last instant of my life. But I need to define myself as more than the grieving husband—the grieving soul mate.
…I know too many people…
The months from August to December have always been hard since Jane’s diagnosis and death. Every day holds a new trigger for grief. And this year their power is greater than ever before. The tears have come daily for the last week. My mind reels from memory to memory.
The heart of things
Yet, in a part of my soul, I know that I am letting go of Jane in a way I have not done until now. I know she is reborn in a new body that does not remember the life we shared together, that is preparing for the new work before her.
The tears have come daily…
And I still have work of my own to do. It is work shaped by the work we had together, shaped by our lives and our deaths—and especially her death in this lifetime. I have pressed forward with that work despite her death and my grief, but my grief has kept me from doing the best I am capable of.
When the heart begins to listen
I have moved forward but I cannot truly move forward until I come to terms with the fact she is dead—that I will never hear her voice again or feel her in my arms. I know it in my head but my heart has refused to listen.
…I still have work of my own to do.
Or maybe it has. Beginning to clear out the basement was not a conscious decision. I went down to put the laundry in the washing machine and, having done that, started cleaning.
The heart moves forward
Taking her pictures down in the living room was not a conscious decision—I saw a way to make the room work a little better by moving three pieces of furniture. When I was done, the collages felt too big for where they were. I took them down and moved them without thinking about it more than what it took to do it.
…my heart has refused to listen.
This morning, I knew it was time to unpack that suitcase—but it is in a closet I can’t easily get at. Once I can, the die is cast.
The topiary heart
Some time back, I wrote a piece about a topiary heart Jane had grown after we were married. It was the only plant that died while we were in the hospital. I discovered another ivy that had somehow survived the neglect that month in another pot.
…the die is cast.
I salvaged the heart form and began a new topiary. This week the sprouts completed the form. The heart is but a single strand thick and not nearly as full and strong as it was—but there. My own heart seems in similar shape—returned from the dead and knitting together, though still far from what it was.
If the heart is healed, can the soul be far behind?
Our original topiary heart was the only plant we lost during Jane’s time in the hospital. About two weeks ago, the heart I started shortly after her death finished filling the form. It is only one strand thick in most places, but one strand is better than none.
Jane was in surgery five years ago today as I write this. Part of me wishes she had had a less competent surgeon that day–someone who would not know how to deal with the damage to the heart he found when he opened her chest. It would have spared her the 25 days that followed.
…the price of all that is beyond counting…
I remember everything about that day in too vivid detail. I remember taking off her wedding ring. I remember the hours in the waiting room. I remember the walk up the street to the church where two friends were married–where Ted Kennedy sat when his son was in surgery–where the “liberal lion” of the Senate had had his funeral. It is all long and silent.
A single day
I remember coming back to the waiting room. I remember them sending me off to eat with a pager in my pocket. I remember coming back and watching the other people leave, until I was the only person left. I remember them closing the room and sending me to a waiting area of the sixth floor, right outside the ICU where Jane would arrive after the surgery.
It is all long and silent.
I remember trying to distract myself with television shows. I paced. I looked out the window at the street below and at the buildings across the street. And I remember thinking, this is taking too long–something is wrong.
Living and dying
And something was. The valves in the right side of Jane’s heart were so damaged that the serotonin had begun damaging the area where the new valves were supposed to attach. The surgeon had to sculpt a new seating for them into the flesh of Jane’s heart. A lesser surgeon would not have seen in his mind how to do that. A lesser surgeon would have been forced to let her die.
…something is wrong.
Sometimes I think about the what-ifs of that night. I wonder what would have happened if the surgeon had come to me and told me she was gone. I wonder if her death would have been harder or easier to bear. I wonder if I would be doing what I am doing now. I wonder how my relationship with her doctors would have been different–my relationship with our friends.
The day the world changed
I do know that there are people alive today who would not be if that had happened. They had heart surgery after Jane battled through four carcinoid crises–the last of which killed her. Her doctors learned from those and what they did to stop them. There is consolation in that–but it has not stopped the tears, especially not today.
…I think about the what-ifs…
I went to the wake for the father of some friends this afternoon. Jane and I had his grandchildren in class. They were the kinds of kids you don’t forget. Jane would be proud of them and the people they have become–as am I. She should have been there in more than spirit to see them.
Too much memory
A memorial service was held right after the wake. I’d planned to stay for it. But I could feel the tide rising. I had to get out of there before I lost it. Seeing our friends was one thing–seeing our students in that setting–was too much. Maybe on a different day than this one, it would have been different. But today…
There is consolation in that…
Today, I realized Jane really didn’t come out of that surgery. Her body worked–sort of. The heart pumped and the lungs pushed air in and out. The mouth formed words. But the anesthesia clouded her mind so badly she didn’t know what day it was until December 3. And the endless diarrhea stripped off her dignity more rapidly than her weight.
Forging tomorrow
Yet she stayed with me as much as she could for 25 days–and we forged something out of those days. I don’t know who I’d be without those last fragmentary days–or what I would be doing. I don’t know how many lives we touched in those days–nor how many since and in the future. I think I am a better person than I would have been without them.
Her body worked…
But the price of all that is beyond counting–and today it hurts more than I can say.
Every day this month I try to do something to raise awareness about NETs. It is doubly difficult because the these days encompass the worst days in my life.
Grades closed for the first quarter at my high school five years ago today. I was supposed to finish grading some papers by Friday so I could post them on the computer before report cards were printed and sent out. But I also knew Jane and I were headed to Boston the next morning for another meeting with Jen Chan, her oncologist at Dana-Farber. I was worried about that appointment in ways I hadn’t been before.
…Jane’s body died and took part of my soul with it
Jane’s legs and abdomen were more swollen than they had been just two weeks before. She had stopped going to the basement entirely and the previous weekend had sent me out alone to do the grocery shopping. Neither the long-term Sandostatin nor the multiple daily octreotide injections seemed to be doing much good. But I worked hard not to let her see I was worried. I wanted her to stay optimistic.
Anger explodes
I know now that Jane was equally concerned. She had seen our neighbors a few weeks before–just prior to their departure for Florida for the winter. She’d told them she didn’t expect to be here when they came back. She felt, I think, that she needed to stay positive for me the same way I felt that for her.
I was worried…
I’d spent the previous weekend buttoning up the gardens around the house and giving the lawn a final mowing. As I carried a pile of brush to the composter, my foot went through the sod into a sinkhole. I lost my mind for a few seconds. It made me insanely angry and I let all the pent-up anger and frustration of the last several months boil out of me in a primal scream.
Explaining anger
The anger hadn’t entirely dissipated by the time I came back in. My voice was still strongly tinged with anger when I told Jane what had happened. “Why are you more angry at this than you ever are about my cancer?” she asked. Her own voice was tinged with anger and hurt.
I lost my mind for a few seconds.
So I told her. I was calm about it–completely rational. I told her I was absolutely furious about her cancer–and I was. But I didn’t dare let that anger and hurt and frustration out. I had to stay calm because I had to be able to hear what her doctors were saying to us and understand it. I needed to be able to listen critically to what they told us so that I could ask the questions whose answers terrified us but that we needed to hear.
Caregiver anger
And I told her I was terrified that if I let that anger out some of it would splash over on her. She hurt badly enough, I said. I didn’t want to add to that hurt. “I hate this cancer,” I said. “I hate what it does to you. I hate that it makes you angry–hate that the anger gets directed at me sometimes. But when you get angry with me I remind myself that most of the time it is the cancer talking–and not you–and that if I let myself get angry back it isn’t going to help anything.”
I was absolutely furious about her cancer…
I’d watched her get ready to give herself an injection every morning for months. I’d watched her prep the hypodermic, draw out the fluid, cleanse her belly with alcohol swabs, then push the needle into her body and press down on the plunger. I’d watched her go through the same procedure every night, knowing that earlier in the day she had done the same thing when I was not around.
Bargaining in anger
I could see the marks the injections had left on her stomach. I knew there were ways I could not touch her without causing her pain–even a hug could be too much. And I could see how little good those injections seemed to be. It hurt me in my soul to see all that and know all I could do was hold her hand and smile and whisper constant encouragement.
She hurt badly enough…
There were times, when I was alone, that I looked at the heavens and said, “If you’re going to take her, do it quickly and be done with it.” I felt guilty every time I said that–truth be told, I still do. It’s a horrible thing to wish for the death of someone you love. It feels like the worst kind of betrayal no matter how much it may seem like the merciful thing to do.
Changing the landscape
We didn’t know, as we got into bed that night, that Jane had just a month left to live. We didn’t know that we would sleep in the same bed just three more times. She was, however, smart enough to make sure we said our good-byes that weekend after her heart surgery was set for the following Monday. She told me she fully expected to come home again–that she would not die from this surgery or its aftermath–but just in case…
It feels like the worst kind of betrayal…
A lot has happened in the 59 months since Jane died in my arms. The landscape of NET cancer has changed in some significant ways. Most of it has nothing to do with Jane’s death or my actions since then. Most of it was already in the pipeline. I’m not sure anything major changes in treatment or research if I had just curled up in a ball around my grief and disappeared.
What I might have done
Part of me wishes I had done just that. Perhaps then I would not still find myself wandering the house–moving from room to room aimlessly and watching hours vanish with no idea where they have gone. Perhaps then I would not have a dozen projects lying around me half-finished. Perhaps then I would have done what Jane asked me to do in that long Saturday conversation where we said good-bye.
The landscape of NET cancer has changed…
She told me she loved me; that she wanted me to find joy in life again, wanted me to fall in love again; that she fully expected me to go on with my life. Instead I dream of her last months and of trying to find her when we get separated in a store or in the woods. I dream she is lying next to me–and then wake up to find my arms wrapped around a pillow.
What we did and what I do
Every day, I get up. I eat breakfast. I read the newspaper. I craft a list of things I need to do.
Then I sit down and try to do the one thing I know really makes a difference: work to bring hope to patients and caregivers. Some days it’s comforting patients; some days it’s trying to figure out how to explain the latest bit of science; some days it’s helping caregivers understand what they are feeling is normal; some days it’s helping those who mourn find ways to cope; some days it’s trying to figure out how to raise a few more dollars for research; some days it’s about trying to build structures that will help people when I can’t do this any more.
…I dream of her last months…
Fifty-nine months ago today, Jane’s body died and took part of my soul with it. Fifty-nine months ago today, I stopped being Jane’s caregiver and returned to the work we had always done together: trying to help those who needed what we had to give.
Anger and grief fuel my Walk for the Jimmy Fund every year. But no matter what I do, it never feels like enough–and it never alleviates entirely either emotion for very long.
Good morning and welcome to Walking with Jane’s third annual NET Cancer Awareness Day Social Mediathon. I’m Harry Proudfoot, the president of Walking with Jane, and I ‘ll be your host and guide for the next 18 hours as we explore not only what is going on elsewhere on this special day, but also what the latest news is on several fronts in the ongoing fight to help NET cancer patients and their loved ones.
You can follow this social media event in several ways: you can log into walkingwithjane.org, watch our Facebook page or the NETwalkers Alliance Facebook page, follow us on twitter (walking with jane @ Harry Proudfoot), check in on our Pinterest page, go to our Google+ page, or follow things on our Tumblr. You can post NET Cancer Day pictures to our Instagram (@walkingwithjane) or share them to any of the above you can reach. You can also comment on any of the above that accept comments. Please feel free to share what you find here with others.
Disclaimers and cautions
Before we go any further, I need to make a couple of things clear: First, I am not a doctor. None of what you read here today–or on any of our social media platforms–constitutes medical advice of any kind. If you see something today you think might be useful, your first stop needs to be a conversation with your own doctor or a NET cancer specialist. You can find a list of people who specialize in the treatment of NET cancer here. The Carcinoid Cancer Foundation--which we’ll talk about later–maintains that list.
You should also know that when I discuss the disease, treatments, and research that I am merely an educated layperson. My degrees are in English, not science or medicine. What I know I know because of the reading I’ve done, of the conferences I’ve attended, of the conversations with doctors I’ve had, and because of the things I learned during the time my wife was dying from NET cancer in 2010. I’ll talk about that last experience in more detail later today. For now, I will only say that today also marks 59 months since her death.
6:15
People periodically ask me why, almost five years after Jane’s death, I am still involved with the disease. They ask if dealing with the thing that killed my wife every day doesn’t prohibit–or at least slow–my own healing. The answer to the first question is easy: I watched what happened to Jane over the last months of her life; saw how little there was we could do for her; and realized very quickly she was not the only person going through what she was going through.
My wife–who was diagnosed very late in the course of the disease– knew from very early on how deeply the deck was stacked against her. Before she saw her doctor at Dana-Farber, she agreed to be part of a clinical study she knew would have no impact on the success or failure of her own treatment. She knew how little scientists and doctors knew about NET cancer and knew the only way she could help was to let them study what was going on with her.
Jane and I took our marriage very seriously. We believed that on the day of our marriage we ceased to be two people. We were one–and a promise made by one was a promise made by both. That’s not to say we did not have independent lives and interests–we did, and we pursued those things. But neither of us made life decisions without the other. Part of my job, as Jane slid in and out of consciousness, was to make sure her doctors learned everything they could.
I became a close observer of what was going on with her. I knew how frequent her diarrhea was, how much was in each bowel movement, how she looked when she came out of heart surgery, what a full-blown carcinoid crisis looked like. I helped change her bedclothes. I watched her die micron by micron.
Thirty-four people die that death, on average, every day. That number will begin to increase in the near future if nothing changes because we are now diagnosing significantly more cases than we were when Jane was diagnosed. I don’t want anyone to die that death. To prevent that, I have to be as involved as I can in helping raise awareness of the disease; be as involved as possible in creating the resources for the research from which we will eventually get a cure.
The second question is more complicated. But the answer to it doesn’t really matter in the larger context. Nothing compares with what Jane went through that I am determined to prevent others from experiencing. To do otherwise, for me, would dishonor her life and mean turning my back on everything we believed in.
But first, if you are new to NET cancer, I think it’s important we talk about exactly what this supposedly rare–and definitely out of the ordinary–cancer is and what makes it so difficult to diagnose and treat. While we do that here, I want to suggest those of you who already know the basics take a look at this video from last month’s Dana-Farber Cancer Institute Visiting Committee presentation. While it doesn’t directly address NET cancer, it makes a connection that is guiding the search for not only for a NET cure, but also cures for all other forms of cancer. Of course a review of the basics is always a good idea–so if you’d rather…
We have a lot of names for this cancer: neuroendocrine cancer, carcinoid cancer, NET cancer, NET. And we have a number of names for the cancer based on where it is and what it does. For example, pancreatic NETs describes a range of neuroendocrine tumors that form in the pancreas. Those tumors are different from the pancreatic cancer most people are familiar with.
Neuroendocrine tumors (NETs) get their start in cells that are part of the neuroendocrine system. That’s the system that creates all the hormones and peptides the body uses for a variety of purposes ranging from growth to sex to digestion to sleep patterns. In all, the body uses more than 24,000 of these chemical compounds to regulate just about every biological process we engage in.
Neuroendocrine cells are just about everywhere in the body, so at least theoretically, a NET can form just about anywhere. And they do. NETs form in the lungs, on the thyroid and thymus glands, in the ovaries and the prostate–just about everywhere. But the ones we find most frequently are associated with the intestinal tract and pancreas.
NET cancers are very different from the vast majority of solid tumor cancers we most often think of when we think of cancer. Most cancerous tumors grow very rapidly compared to the normal cells around them. But, with some notable exceptions, most neuroendocrine tumors (NETs) grow fairly slowly. My wife’s first symptoms appeared thirty years before the disease killed her–and she did not learn she had cancer until just four months before she died.
The second difference has to do with the size of the primary tumor. Most solid tumors get fairly large before they begin to spread. But a primary NET often does not get much bigger than a lentil before daughter cells begin turning up elsewhere. And those daughter cells can spread fairly rapidly, making a surgical cure difficult if the disease isn’t caught very early.
Normal cancers–if we can call cancer normal–are relatively inert. They take up space, consume resources like food and oxygen, and gradually destroy the organs they come in contact with, leading to the death of the patient. NETs can do similar things, albeit in slightly different ways. A collection of NETs in the intestines can cause a blockage; NETs that have metastasized to the liver sometimes explode in size very rapidly, but a large number of smaller NETs can effectively destroy the liver’s function just as well.
6:45
But some NETs bring a new player onto the board. About 30 percent of all NETs produce hormones–and can produce them in sufficient quantities to have an impact on body chemistry and function. For example, a pancreatic NET might produce extra insulin. Too much insulin leads to an increased metabolic rate, meaning the body burns through its food supply too rapidly.
When a NET produces a hormone, we say the tumor is functional. When it does not appear to be producing a hormone, it is called a non-functional NET. Any time a NET produces a hormone that causes a disruption in the normal processes of the body we say the patient has carcinoid syndrome. We don’t understand why some NETs produce hormones and other appear not to.
In my wife’s case, her tumors were producing serotonin. Initially, this caused frequent painful gas and diarrhea as her body digested food too fast for her intestines to handle. She was, in fact, digesting her food so fast that it left her body before she could absorb all the nutrients in what she ate. But serotonin also regulates sleep–and too much meant she spent years suffering from insomnia. In addition, it regulates blood pressure–so Jane dealt with low blood pressure that led to fainting spells if she got up too fast. She had frequent flushing episodes that doctors chalked up to early menopause. Her digestive issues were irritable bowel syndrome caused by the stress of her job–which also explained her insomnia.
Serotonin is a chemically hot hormone. Normally, it is metabolized in the liver, so its impact never gets outside of the areas it is “safe” for it to be in. But if a NET that is producing serotonin forms in the liver, the liver never gets a chance to destroy it. That hot chemical travels up through the valves in the right side of the heart and eventually destroys them, leading to right-side heart failure. This is called carcinoid heart disease.
Jane already had advanced carcinoid heart disease when she was diagnosed–and that is what ultimately landed her in the hospital. On November 14, 2010, she had open-heart surgery to replace both valves in the right side of her heart with mechanical valves. Surgeons often use pig valves for these replacements because they are less likely to create blood clots. But for carcinoid patients with serotonin coming out of the liver in quantity, those organic valves are a bad idea because they will burn out the same way the originals did. The mechanical valves are not organic and don’t react with serotonin.
7:00 a.m.
(We’ve had our first technical glitch of the morning. The 7 a.m update did not load–it ended up in an endless loop. So I am trying again. The 7:15 update will follow shortly–assuming this uploads properly in the meantime.)
We have a couple of comments already. The first is from Toba Woodruff and gives us a little background into heroine NET experience:
I was diagnosed with BC left lung and had a left upper lobectomy in December 2010. I was told I had intestinal inflammation. Should have known it was more.
What with the second Cat Scan asst. guided needle biopsy that was aborted after they “bent the needle” I decided I’d had enough and was not going on with that procedure. As I said I was told about the “Intestinal Inflammation” for a year. Went for a 1 year cat scan and they “discovered” the pancreatic neuroendcrine tumor. I had a Whipple in April of 2012. Changed hospitals and Surgeons too. Doing pretty well now.
Use Dr. Shumaker in Jackson, MS (But really only for Sando orders and 3 months checks) Use Woltering in Kenner, LA for 6 month checks. So, sorry you lost your wife. Thank you for doing this.
The other comment comes from a FB conversation with Ellen from just after 6 a.m.:
WWJ: You’re up early. Is there anything in particular you are looking forward to hearing about today?
Ellen: Yes, for some reason I got up at 3:30am…..perhaps because it is NET / Carcinoid Cancer Awareness Day! I am looking forward to hearing about the new treatments available, especially for survivors who have had many, many years of surgeries, ablations, radiation etc.
We’ll be looking at those things in some detail later this morning.
7:15 a.m.
But first, I want to finish the background to the disease we started on earlier. Here’s the next piece of that.
Despite a major complication during Jane’s heart surgery–the serotonin had begun working on the actual heart muscle–the surgery went well, as did the initial phases of her recovery. The valves gave a happy click-click with every heartbeat and we were ready to head for the step-down unit two days after the surgery.
Unfortunately, any kind of operation on a carcinoid patient can set off what is called a carcinoid attack in which, for reasons we don’t fully understand, the tumors kick into high gear and start producing even greater amounts of whatever hormone they are putting out. Sometimes, those are caused by the anesthesia–but other times the cause is less clear.
Doctors knew about carcinoid crises in 2010 and took steps to prevent it from happening, in Jane’s case, by administering a significant amount of octreotide before, during, and immediately after surgery. Jane had one two days after surgery–right after she started physical therapy–despite those precautions. Today, the protocols are significantly different from what they were then because of what happened with Jane.
But all of that could have been avoided if we’d simply had better tools for diagnosis and more awareness among doctors. Early detection of this cancer is supremely important. Unfortunately, those are still issues we are dealing with.
7:30 a.m.
Most patients are not diagnosed until they have fairly advanced disease, In fact, the average patient still goes through at least three incorrect diagnoses and seven years of testing before a NET is discovered. They have a vague range of symptoms that point to other “more common” diseases. There are no easily palpated or detected lumps that scream cancer–the primary and immediate daughter tumors are too small–until they hit the liver and sometimes, but not always, explode in size.On paper, we have three blood tests and a urine test that can, potentially, detect the disease. The Chromagranin A blood test has been around for a number of years, but is not very reliable–at best it picks up 60 percent of the cases–and throws off a number of false positives. It is used more to monitor the progress of the disease more than anything else. The 24-hour 5-HIAA urine test detects NETs that produce serotonin, but not others. A blood test to do the same thing has had some successful trials, but suffers from the same weakness–it only picks up the tumors that produce serotonin. The final test–the NETest–looks a broad range of markers but has not yet had for a formal trial and is currently used by some doctors to monitor disease progress in patients who have already been diagnosed.
The tumors are nearly always invisible on most scans. Two new scans, developed in recent years, have improved that situation in at least some cases. The more widely available is a PET scan called an Octreoscan that uses octreotide to light up the receptors on the tumors. The Gallium-68 scan uses Gallium-68 as its painting agent has just finished a series of trials at NIH and shows a much sharper image than does the Octreoscan. But tumors without the appropriate receptors would remain invisible–and such tumors appear to exist.
In any case, the primary care physician has to decide to pursue a NET cancer possibility. My niece, who is now in residency in California, says her medical school did talk a great deal about NETs on the diagnostic side, so young doctors are more likely, perhaps, to include it in their thinking when looking at a patient.
I need to underline here that my example here is Jane, who had tumors producing serotonin. Other people have different hormones involved, which means a different set of vague symptoms–and the need for, potentially, different kinds of tests and treatments.
Understand, too, that what we’ve just done is a very brief overview of the disease and how we diagnose it. We’ll talk about prognoses and treatments later in the day. But if you want a much more detailed explanation of all of the above, the Healing NET Foundation has a lengthy primer on NET you can download here for free. It is very well done, but aimed at medical professionals, though I found it pretty easy to read.
One of the other things we’ll do today is meet some people who are dealing with this disease in their daily lives, whether as patients, caregivers, or people who have lost someone they love to it. I sent out a request for volunteers, as well as some questions. Some of these will follow a Q&A format, some do not. If you’d like us to highlight your story, it’s not too late. Just write your answers to the questions in this first interview and send them to me at walkingwithjane@gmail.com.
I’d particularly like to hear from more caregivers. My plan is to spend an entire hour talking about what it is like to be a caregiver and what those largely ignored people in the background of cancer face later in the day
Our first guest writer of the day is Dian, who is a NET cancer patient in Texas.
Dian’s story for NET Cancer Day
What is your name?
Dian
Where are you living?
Pearland, Texas
Describe how you found out you had NETs. What problems did you have getting the right diagnosis?
The surgeon had just finished a gastric bypass reversal and was routinely checking to show med students when he accidentally found carcinoid tumor in mid-gut.
When were you diagnosed?
2009
What problems does your NET cancer create for you? What is your typical day like?
Dealing with NETs Diarrhea. On meds, down from 10 or more episodes to about 4 daily. Full carcinoid syndrome daily but helped a lot with meds.. just not totally gone.
For example flushing /heart palpitations with exertion. Some shortness of breath. Extreme fatigue on most days. Have to know where bathrooms are. Overall aching pain and some midgut and pelvic area pain from levels of pain 3-8 daily. Interference with sugar and thyroid levels from Somauline.
What treatments have you had? Did they work for you? What kinds of side effects have you experienced from treatment?
Two surgeries to remove tumors, then told that tumors were seeded and implanted in mesentery and pelvis area are too many to count. Because I also have pulmonary fibrosis and kidney problems I am not a good candidate for further surgery.
I’m on Somauline 120 mg./28 days inj. , Lomotil 2 tabs 4 times a day and other meds for diabetes and thyroid cancer. Also 4 liters of oxygen.
Can’t make plans for outings because of either diarrhea, fatigue or pain issues. Coping on a dairy basis, some days are better than others. I focus on good days.
How does where you live affect your ability to get treated for NET cancer?
Finally found a nearby NET oncologist–he has MEN, and understands. Dr. Mark Lewis, Sugarland, Texas. MD Anderson. Traveling has become more difficult for me, but I have seen Drs. Woltering and Liu.
What is your biggest frustration?
Extreme fatigue, diarrhea, and insomnia.
I’m so sorry for your loss. Jane sounds like she was an amazing person I would have wanted to meet. Thank you so very much for all that you do to help us. It does help. You have and are bringing awareness of this horrible cancer. If this knowledge had been there when I first started being sick in my 30s it would have made a big difference.
We know from records and hindsight that my tumor started IN my small intestine. Had it been found and removed my life today would be different. It went undiagnosed until it grew and tore out of the small intestine to nest on top of the intestines AND GROW. That’s why it is so widespread now–including the lymph system. I went to so many doctors including specialists with classic Carcinoid Syndrome from the beginning of my sickness in my mid-30s. None of them ever suspected or tested for carcinoid.
Also, after working 22 yrs. I was denied SS disability benefits because I could never get a doctor to diagnose me correctly.
God bless you and thank you again,
Dian
8 a.m.
Dian’s story underlines another serious problem NET patients face: the problem of finding an oncologist who specializes in NETs. As I said earlier, the Carcinoid Cancer Foundation maintains a list of NET specialists by state. But in too many states there are simply no expert oncologists available. That means too many patients have to travel too many miles to find someone who knows what they are doing.
The list also differentiates between those who are actively involved in research and have significant experience with the disease and those with less of a track record. There are not a lot of folks in that first group. No matter how you look at it, we need more NET cancer doctors because this cancer plays by very different rules than the other, more well-known ones do–and never mind that the small number of doctors we do have face a rising tide of patients.
There is some good news on that front–at least locally. When Jane was diagnosed, Dana-Farber had just one doctor working full-time on NETs. Jen Chan, who became Jane’s doctor, only spent half her clinic time seeing NET patients. Within a year of Jane’s death, all her clinical and research time were spent on NET–and they still needed more doctor time in the clinic. This year, DFCI has hired two new oncologists with an interest in NETs and carcinoid who will spend part of their time with NET patients.
That kind of increase needs to be replicated nationally, though. In 2010, we had 10-11,000 patients diagnosed with the disease. Last year, we had around 15,000 according to a couple of sources in a position to know. The last official count put the number of people who are knowingly living with the disease at about 110-120,000. But if we are now adding 15,000 new patients a year to that list, that number is going to swell fairly rapidly.
The equally important question is, where are those new cases coming from? And the short answer is, we don’t know. It may be we have significantly increased awareness among primary care physicians in the last five years. Given the increase in publications about NETs in major journals and at conferences–and the possible increased focus of medical schools on the disease evidenced by my niece’s experience–that seems like a possibility.
The improvements in scanning technology I mentioned earlier, may also be playing a role, especially if they are being utilized more by doctors more aware of the disease and the existence of those scans.
But it is also possible there is something environmental going on. I’m increasingly reading about cases of people in their 20s and early 30s being diagnosed with significantly advanced disease. I have a friend, who has written here earlier, who underwent her first liver embolization in her early 30s. We lost a young woman just over a year ago who was only in her late 20s. And I’ve seen one report of a nine-year-old diagnosed with full carcinoid syndrome.
My hope is that cases like these have always existed–we just didn’t know they were there because the expectation was this disease hit an older population and we were not looking for it elsewhere. In reading some of the older studies, that certainly seems it might well be the case.
The one thing we can say for certain is we are seeing more cases diagnosed–and that means we need more doctors and more researchers–more everything, really. And we can’t do that with a research budget that–for all that, too, has increased over the last five years–still amounts to a rounding error on what we spend on lung cancer or breast cancer or prostate cancer.
Time for a quick update on how we’re doing. So far, 68 people have logged into the main Social Mediathon site and our Facebook audience has swelled to nearly 700. That’s well ahead of where we were last year at this point.
Time to brighten our Social Mediathon page with our first picture of the day.
This is also a good time to remind all of you that you are free to share everything here with your friends on every social media platform you are part of. I had hoped to add SnapChat to my list this weekend, but that didn’t happen. Still, if you have an acc out there, you can certainly share that with the people you talk to there.
I also have some pictures I want to post as the day goes on. But frankly, I’m running as fast as I can just to keep up with what we’ve posted so far.
8:15 a.m.
At 9 a.m. we’ll break away to spend some time in England with an expert there who is doing a live web chat on NET cancer as part of the British effort on this global NET Cancer Awareness Day. But first, in preparation for that chat, here is a short video from the Royal Free on recent advances in treatment of NETs.
8:30 a.m.
Some comments from people in the audience this morning:
Alicia: Today is NET awareness day! 2 years ago I had never heard of this disease, yet 1 yr and 8 months ago I underwent a surgery to remove a tumor and part of my lung to this disease.. I still have symptoms occasionally and my marker tests are elevated with small nodules in every part of my lung. This disease is real and people die of it and never understand or even know they have… not all cancer is pink! #zebrarare I am so thankful for those who fight to educate and those who live with disease and advocate! It’s our day!EDUCATE!!!
Patient Question: Can’t a radiologist tell the difference between neuroendocrine and others?
Reply from another person:The only way to determine the type of cell would be through a biopsy. The problem is that with this type of cancer most people do not have symptoms until the cancer has already spread. Many in the medical community incorrectly diagnose because they are unfamiliar or unaware of this “rare” type. By spreading information to the medical community and to the general public patients will be diagnosed sooner and will have much better outcomes. Hope this helps.
8:45 a.m.
Kara Daniels is a member of our Boston Marathon Jimmy Fund Walk team. Her story about NETs starts with a cookout.
My name is Kara Daniels, I live in Hopedale, MA and was diagnosed with Neuroendocrine/Carcinoid cancer six years ago, in September 2009. I was very fortunate in being able to be diagnosed fairly quickly.
After being at a cookout on July 4, 2009, I developed severe diarrhea and abdominal pain within 24 hours. It took me several days to call my doctor with my symptoms because, being a nurse, you don’t call your physician just because you have diarrhea. After becoming very dehydrated, I resorted to calling my doctor and being seen.
Of course we both thought I had probably eaten something that may have gone bad at the cookout (you know the story – don’t leave potato salad out in the sun when it’s 90 degrees out) despite the fact that no one else who was at the cookout had become ill. I thought I had gastroenteritis and went on the BRAT diet and had some labs drawn testing me for celiac disease and being lactose intolerant.
My physician told me she didn’t want to do a ct scan at that time stating, “A ct scan is equal to 100 x-rays.” I always laugh at that statement when I think of the 29 ct scans I have had since. She told me to call her in a month if I was not better.
I waited three weeks and called her back. Within those 3 weeks I ended up in the Emergency Room severely dehydrated and requiring several liters of IV fluids. We resorted to the ct scan which, at that time, which showed multiple tumors in my pelvic area.
Initially, it was felt that I had ovarian cancer and I was referred to a Gynecologic Oncologist. After several ultrasounds and being told that I had “totally stumped him with the findings,” he told me it was time for me to have a biopsy–which revealed carcinoid cancer with a primary site of what is believed to be my small bowel with metastasis to my pelvis, around my ovaries, outside my right lung, my abdominal wall and the top of my liver. I had developed my “gastroenteritis” July 4 and had my carcinoid diagnosis by mid September.
As I look back, I did experience diarrhea and flushing before that but thought the flushing was due to my age (43 at the time of diagnosis) and didn’t think much of the diarrhea.
Fortunately I live only an hour away from Dana Farber Cancer Institute in Boston and was extremely lucky to have found Dr. Matthew Kulke. I was immediately started on octreotide injections in October. However, by the following May, my ct scan had shown tumor progression.
At that time I started on a clinical trial of AMG 479. I went in to Dana Farber every three weeks to see my team, receive my infusion of AMG and octreotide injection. I was known as the poster girl for AMG until January of this year when I had more tumor progression, although small, but progression none the less and enough to take me off of the trial.
On to trial number two of cabozantinib. Starting at the highest dose of 60 mg and working my way down to 20 mg, I was not able to tolerate the side effects which included decreased appetite, mouth sores, nausea, extreme fatigue, abnormal lab values, thinning hair, numbness in my hands and pain in my feet–making it difficult to walk at times. Although the side effects were much less with the 20 mg, they still remained. After much soul-searching and talking with my family and closest friends, I decided to stop the trial in July.
I have been feeling great until about a couple of weeks ago, when I had a small setback, but nothing that a week of rest didn’t help. I have tried to not let this slow me down at all and have continued to work through all of this.
It has only been recently that I have come to realize that if I’m tired in the afternoon, it’s ok to rest for a bit. In addition, I have one son, who is a high school senior, and we have been busy applying to colleges–so there’s never a dull moment.
As for my biggest frustration, well, I could list many, from the decreased awareness of NET’s, to people thinking there’s nothing wrong because you “look great,” trying to manage everything you eat and the timing of when you eat, to seeing people with other types of cancers having the entire community come to their rescue. I have to honestly admit, it’s nice to watch the Patriots game today and not see a sea of pink on the television screen.
I have decided to stay off of treatment for now and take a wait and see approach. My last MRI in October–yes, no more ct scans–did not show any tumor progression. I know some may not agree with this approach, but it is more important to me to feel well, not struggle with side effects and have a great quality of life as I do now.
I have to say I am very impressed with the information the chat is providing, especially to individual patients. If you are not following it, you should be. I’ll comment more fully on some of it later.
10:00 a.m.
The web chat has closed from the Royal Free. They will publish answers to any remaining questions later. You can still read the answers to the questions posed there.
Before we go any further, I should point out a site everyone needs too visit today: netcancerday.org. While you are there you can sign up to do a number of things both online and in the real world. And make sure you share their address on FB and twitter–and anywhere else you can think of.
You can also download a Zebra ribbon there for your FB or other social media accounts. I’d love to see lots of zebras everywhere I go today.
This says a lot. The purpose of today is to remind people of a very different form of cancer that does not get very much attention.
At the end of the eight o’clock hour, I posted Kara Daniels’ story. In it, she raised a couple of important issues, not least of which is the lack of understanding about not only NETs but many other forms of cancer that are ignored by the NFL and the general public in the massive pink wave that is October.
I mean no disrespect to those with other forms of cancer–but I truly understand Kara’s comment about watching football in October. This is especially true, however, when I go to the American Cancer Society and look for information about NETs. While a search for many cancers on their website will take you quickly to a page dedicated to that cancer, a search for NETs there will only leave you frustrated.
Please drop the ACS a note–or give them a call–today and ask them to address this problem with their website.
10:30 a.m.
On a more upbeat note, here is a great idea to raise some money for NCAN: do a virtual walk for NET cancer. Here is a link to their Facebook event page. But I am putting the extended post for their event below:
Hope you’ll be joining our ‘Strides for Stripes’ Virtual Walk! Your participation makes life better for thousands of people who suffer from this disease.
The Virtual Walk- Since a virtual walk is one you can walk anywhere…anytime it is good for those who don’t have the time, aren’t close to a live event or can’t physically participate. Below is a guide that’s full of ideas to help you plan your own Virtual Walk (or another fundraising event) and help support the fight against Neuroendocrine Cancer.
Stride for Stripes Walks Fight Neuroendocrine Cancer
As a participant in one of the walks, you are raising money for programs that benefit neuroendocrine cancer patients and raising awareness of neuroendocrine cancer.
Here are things you may not know about this disease:
Carcinoid /NET cancers are known to affect over 125,000 patients in the United States.
12,000 people are diagnosed annually.
Initially, over 90% of all Carcinoid/ NET patients are incorrectly diagnosed and treated for the wrong disease.
Average time from initial onset of symptoms to proper diagnosis exceeds five years.
You can fight neuroendocrine cancer- and be healthy and have fun doing it!
Get a Walk T-Shirt and other great prizes
Raise $35 and you get a cool Strides for Stripes T-shirt.
NOTE: TEE SHIRTS WILL BE AVAILABLE ON OR ABOUT OCTOBER 12TH. IN ORDER TO BE GUARANTEED A SHIRT, PLEASE SIGN UP BY OCTOBER 1ST. DUE TO THE HIGH COST OF SHIPPING, TEE SHIRTS WILL BE SHIPPED WITHIN THE CONTINENTAL UNITED STATES ONLY.
How to Create Your Walk Fundraising Page
Participating is easy and fun. There are two ways to participate:
1) Fundraise for the Walk on your own. By signing up as an individual, you can tell your personal story and family and friends can donate directly to your personal page.
2) Sign up as a team. By creating a team of friends, family and coworkers, each team member can create their own personal page, tell their story, upload pictures and fundraising individually as part of the greater team. You will also have a team pages where you can monitor the success of your team.
Put the Fun in Fundraising!
1. Set up your fundraising webpage
Creating your online fundraising page (personal page) is the fastest and easiest way to receive contributions. You can upload your address book and send everyone a personalized email asking for their support.
2. Tap into your social networks
If you’re on Facebook or Twitter, let friends and family near and far know you’ve joined the Virtual Walk and ask them to support you with a donation. Post periodic updates on your fundraising success to motivate them to get involved.
3. Walk in someone’s honor
Ask for donations to honor a friend, family member or co-worker who has been affected by neuroendocrine cancer
4. Celebrate
If a birthday, anniversary or holiday is coming up, ask family and friends to make a donation to support your participation in the Virtual Walk instead of a gift.
5. Conduct an in-person donation campaign
Go out of your way to meet with and talk to your closest friends and family explaining your reasons for walking and why you chose to support the Neuroendocrine Cancer Awareness Network. Making an effort to reach out on a personal level can mean a lot to your donors.
Take Action, Make a Difference
The power of your contribution…
The money you raise for your Walk will help the Neuroendocrine Cancer Awareness Network continue to provide programs and services essential to neuroendocrine cancer patients.
Here are some of the ways your contribution, large or small, makes a difference:
$15 provides supplies to a patient support group for a month
$25 supplies a comprehensive patient information packet to a neuroendocrine cancer patient, ensuring that the patient will be a good advocate for his/her care
$50 provides DVDs showing cutting edge information from a NET patient conference to a patient
$100 from 20 donors sends an expert to provide urgently needed information at a patient conference
$200 keeps the patient hotline open for a month
$500 sponsors a patient to attend a regional patient conference
$1,000 sponsors a doctor to learn more about neuroendocrine cancer and earn CME credits
$2,000 starts the ball rolling toward funding a research grant
Virtual Walk Guide: Fun Ideas for Your Virtual Walk
VIRTUAL WALKERS- Create your own community fundraising event. Plan a walk or fundraising event in your community. You can plan a walk or another type of event like a wine tasting or a bowl-a-thon. By registering as a community event on the website, your team page would be about your event specifically. Those individuals that choose to join your “team” can fundraise on the website. You can watch the progress of your event and send emails to your contact list encouraging their participation and support.
You may choose to walk around your community, in a local park, indoors at a mall or even on a treadmill at a gym! Your Virtual Walk is a reflection of you, and is as personal as your reasons for joining the fight against this deadly disease.
Be creative! Whether you walk alone, with a friend, or form a team, you’ll be keeping important programs like these available to neuroendocrine cancer patients:
Patient Hotline
Patient Conferences
Information Packets
Support Group Assistance
Funding Research
Awareness Items
Information on Diagnosis and Treatment on our Website & Social Media
Not sure where to start? Here are a few ideas.
Walk in a mall
Take a walking tour of your town
Make your grocery shopping or another shopping trip YOUR walk to fight neuroendocrine cancer
Belong to a gym? Walk a treadmill, and enlist other members to walk with you
Even if you can’t walk, get people involved with a board game, bus trip, beanbag toss- you can be as creative as you want!
Send us a picture. And don’t forget—because this walk is virtual, your team members can be anywhere in the U.S. (Outside the US, please email bob@netcancerawareness.org for more details.)
I think this is a great idea and think that it can serve as a template for other groups to do something similar to support their regional NET cancer center. We’ll come back to the need to support those centers later today.
While the primary focus of this Social Mediathon today is not about raising money, if your NET cancer group has a fundraiser you’d like us to promote today, pass along the information at walkingwithjane@gmail.com and I’ll make sure it finds a place here and on our walkingwithjane.org calendar page.
10:45 a.m.
For Walking with Jane, today is about sharing stories and information. But this seems like a good time to talk about what we’ve been able to do this year financially to help the cause.
The vast majority of the money we raise never passes through our hands here. Instead, it goes directly to the Boston Marathon Jimmy Fund Walk team I captain. This year, we changed the team name to the NETwalkers Alliance because the name better reflected all the different parts of the effort. We’ve tried to gather all the individuals and teams who walk to honor or remember someone with NETs under one big tent with all the money going to NET research at Dana-Farber’s Program in Neuroendocrine and Carcinoid Tumors.
That team raised a total of $67,701. While $30,000 of that is attached to my name, I didn’t raise all of that by a long shot. Gail Silvia organized a dinner that raised $3000, others carried the weight for our Walking with Jane Miniature Golf Open. Friends helped stuff envelopes for two other fundraisers.
The biggest single fundraiser by any team member was the Hank Landers Memorial Golf Tournament run by his daughter, Jenaleigh. It pulled in close to $8000. We had nine people raise more than $1500 on a team with 33 members.
Of course we’d hoped for more. Our goal was a team with 60 walkers that would raise $80,000. Next year, we’ll get there.
In addition, The Walking with Jane Fund for NET Cancer at DFCI will finish its commitment to raise $100,000 over five years at the end of December. I plan to continue that commitment over the next five years in a similar amount. That money goes directly to that fund as well, without seeing the inside of the Walking with Jane bank account.
We also handed out $5500 in scholarships this year to undergraduates planning to enter medicine or science teaching when they finish their degrees. Most of that money goes to graduates of the school Jane and I taught at, but one scholarship goes to a student at Jane’s alma mater, Bridgewater State University.
We also had a Walking with Jane team at this year’s Relay for Life of Greater Fall River. That team raised about $7500 which will go largely to patient support services.
But first, we need to return to the discussion we started earlier about NET cancer basics. We haven’t talked at all about the prognosis for patients beyond saying that there is no cure save early surgery. But that doesn’t mean people can’t live for a significant amount of time with a good quality of life. Prognosis currently depends as much on the stage of the disease and something called tumor grade.
Ronny Allen is a patient who blogs on NET cancer in language lay people can understand. About a month ago, he took on both those issues. His explanation is about as good as I’ve seen. You should read it now.
11:30 a.m.
As I said, Ronny doesn’t just write about NET cancer–he is also a patient, and is actively involved in England, and around the world on NET cancer issues. Here is his profile.
What is your name? – Ronny Allan
Where are you living? UK (England)
Describe how you found out you had NETs. What problems did you have getting the right diagnosis?
After a routine set of regular bloods, I was diagnosed by my GP/PCP) with Iron Deficiency Anemia and referred to a specialist (quite low hemoglobin). The specialist was immediately suspicious and bypassed a colonoscopy and sent me for a CT scan which highlighted numerous tumours in the GI tract including the liver. I was eventually diagnosed with Metastatic NETs (small intestine). I was one of the lucky ones, although I did have a colonoscopy (negative) 18 months prior due to an temporary episode of a darkening stool.
When were you diagnosed? July 2010.
What problems does your NET cancer create for you? What is your typical day like dealing with NETs?
I am pretty stable and am bothered mainly by a compromised digestive system which I mostly address via diet and supplements. I can get tired easily and I have taken early retirement to focus on my health.
What treatments have you had? Did they work for you? What kinds of side effects have you experienced from treatment?
I have had 2 large surgeries (1. terminal ileum, right hemicolectomy, mesentery tidy up plus removal of retroperitoneal fibrosis. 2. Liver resection. Two smaller surgeries – 1. Left axillary lymph nodes x 9. 2. Left clavicle lymph nodes x 5. Plus several others issues – you can read all of this is more detail here: http://wp.me/P4AplF-PQ.
I’m stabilized on Lanreotide every 28 days. I think the early and speedy treatment I received is why I am in good shape today and look well (!). In addition to me giving up work (4 years after diagnosis), the consequences of my cancer and treatment are that my digestive system is compromised, my general immune system is less efficient so I need to be careful with other illnesses which might have a worse effect than they would with a regular guy.
I had lung blood clots early on and have been treated with blood thinners since – this is a minor inconvenience although I’d rather not have it. I have mild lymphedema in my left hand as a result of left axillary surgery (9 lymph nodes removed). I have a (currently) benign lesion on my thyroid.
Living with the knowledge of all these side effects and the potential for new problems to come along is not easy.
11:45 a.m.
I don’t know much about Paraganglioma Jugulare beyond that it is one of the rarest forms of NETs. Sandra Louise Murray responded to my request that she write something about her experience with it. This is what she wrote:
I was diagnosed with an inoperable Paraganglioma Jugulare ( Skull based brain tumor) Aug 2013. My symptoms had started noticeably that June when I developed severe tinnitus, severe headaches, and uncontrollable night sweats.
I had already been experiencing episodes of unexplainable “Flushing” and high blood pressure for many years. Late July, I had a very severe episode of prolonged vomiting while working an international flight from Istanbul to JFK. (I am an international flight attendant currently on disability while I fight this disease). The vomiting was so violent that I pulled and permanently damaged my iliopsoas muscle and also caused a hernia.
An MRI diagnosed me with a subdural hematoma, cerebral spinal fluid leak, a cervical spine tumor and the inoperable Paraganglioma.
Pheochromocytoma and Paraganglioma are NET cancers.
This NET cancer is very rare…only about one in one million people will develop this cancer.
My tumor is radiation and chemo resistant…..thus making treatment most challenging. And, of course, very few doctors have any experience with this disease, making recovery even more challenging. I struggle daily with the tinnitus, headaches and night sweats. Getting a decent night sleep is impossible.
I am very fortunate to be in a Pheochromocytoma and Paraganglioma protocol at The National Institutes of Health in Bethesda, Md. headed by Dr Karel Pacak. Dr Pacak has dedicated his life to finding a cure for this NET cancer. I go to the NIH for regular screening. They have types of PET and CT and other nuclear medicine scans for diagnosing and treating this disease that are not available any other place in the world.
I have been accepted at Massachusetts General Hospital in Boston to start 6 weeks of Proton Beam radiation treatment. I, also, have been accepted at the Mayo Clinic in Rochester, Minnesota for Gamma Knife radio surgery. I have not yet decided which treatment has the least likely chance of collateral damage to the cranial nerves and brain.
Today I will hope for better worldwide NET Cancer Awareness and I pray that all of us who suffer with NET cancer will one day find a cure. God Bless all Zebras…..and all cancer patients worldwide.
Noon
Dr. Eric Liu, a surgeon who specializes in NETs, has made a number of media and social media appearances today. While many of these have passed, you may be able to access them via the stations websites or FB pages.
Friends happy NETs day!
If you are interested and have time, I’m going to spread the word through media today.
Get out there and make sure people know who we are!
Six hours in and it’s time to look at some metrics. We have 210 hits on the walkingwithjane website to this point and an audience of over 1650 on Facebook. Metrics on other sites are less clear, but it would appear we are on a pace that is well ahead of last year.
I’m also told a Cincinnati television station has a link to our Walking with Jane Facebook page on their site.
Lucy Wiley sends the following. Please note her clarification on what I wrote earlier about how some NETs remain invisible even on the latest scans.
Such a timely and interesting post – from the hearts of those who have dealt or continue to deal with NET. Thank you, Mr. Proudfoot. Just one small correction if I may: “But tumors without the appropriate receptors would remain invisible–and such tumors appear to exist.” The atypical, more aggressive form of NET frequently does not develop the receptors that allow it to be seen on octreotide-based scans such as the “Octreo-scan” or the 68-Gallium PET/CT. These tumors also may occur in more diffuse formations and may also develop outside the digestive tract in breast, lung and pancreatic tissue as well as some other unusual sites.
And Bella sends the following comment: Thank you for all that you are doing to raise awareness for this relatively unknown disease and I am sorry for your loss. I have the usual story of misdiagnosis (8 years) and multiple treatments since (surgeries, chemotherapy, radiotherapy) but I’m still going strong. For a lot of us this disease is a long-term companion and the treatment is a marathon so any support is appreciated. Once again, thanks for the great work you are doing. Bella from London, UK.
What are the rest of you thinking? And what would you like to see as we head into the afternoon on the East Coast of the US?
12:30 p.m.
Next, let’s take a brief look into just the scale of the research going on in NET cancer this year. In September, more 25 different presentations on NETs were given at the European Cancer Congress in Vienna. Less than a month later, 67 papers and posters were given at the North American Neuroendocrine Tumor Society meeting in Austin. While there is some overlap, that is a significant increase over where things stood just five years ago.
Two topics in particular leapt out at me from those conferences. The first was the announcement of the results of the Phase III trial of telotristat etiprate, which I wrote about back in August following the initial announcement of those results. One bit of additional news released beyond what we reported in August was that one of the adverse effects was depression. Two patients in the 250 mg group and eight in the 500 mg group experienced depression during the trial. However, the abstract says these and other adverse effects were resolved over the course of the trial. Eighty-six percent of those involved in all arms of the trial continued on the 500 mg dose after the conclusion of the trial.
Further, a separate presentation on the opinions of participants in the trial showed very positive feelings about the impact of the treatment on their daily lives. The vast majority reported the decrease in bowel movements, in particular, had a positive impact on their social and work lives.
Significant decreases in flushing episodes were also reported in the primary paper.
The second thing coming out of those meetings was the long-awaited results of the PRRT trials in the US and Europe. The results were stunning. The study involved over 200 patents and took place in 50 cancer centers–35 in Europe and 15 in the US. Half the patients received the standard high-dose octreotide LAR injections at 60 mg every four weeks while the other half received PRRT using 177 Lutetium-Dotatate in four doses over eight weeks in addition to a 30mg dose of LAR every four weeks.
The PRRT group had a 79 percent improvement in Progression Free Survival compared with the LAR group. Median PFS for LAR is 8.4 months. Data for the PRRT group had not yet matured, but was projected at 40 months, according to Dr. Jonathan Strosberg, a Moffet Cancer Center oncologist and researcher who presented the results.
Thirteen patients in the PRRT group had died during the study, compared with 22 in the LAR group. However, there were more serious adverse reactions (nine percent) among the PRRT group than in the LAR group (one percent).
The NETTER-1 trial was the first randomized, prospective Phase 3 trial of 177 Lutetium-Dotatate for midgut NET patients. The drug has fast-track status from the FDA and these results could lead to rapid approval for the treatment in the US.
Follow-ups on patients in the trial will continue through February 2020.
Another paper caught my eye that should be of interest to NET patients concerned the use of Everolimus on non-functional midgut and lung NETs. Everolimus is already part of the standard of care for pNETs, having been approved by the FDA in 2011.
The RADIANT-4 study, a large Phase 3 controlled trial, looked at the efficacy of Everolimus in advanced, progressive forms of these tumors in 302 patients. The mTOR inhibitor showed a 52 percent reduction in progression or death vs. a placebo and an increased period of PFS of 7.1 months.
A separate Phase 2 trial of Everolimus combined with Bevacizumab in pNET patients also looked promising–improving PFS over the use of Everolimus alone. However, the combination did result in an increase in adverse reactions compared to Everolimus by itself. The study calls for further investigation.
Of less immediate interest to patients and caregivers are a number of studies looking at how NETs work and creating research tools. including a new pancreatic NETs cell line that will help develop new medicines for that form of the disease more quickly. For researchers, however, the kinds of things are supremely important.
And in the longterm, improving our understanding of how these cancers work is where the breakthroughs will come from–and we need big breakthroughs. The new treatments we’ve talked about above all suffer from the same problem: they address the symptoms of the disease; they slow down the progression of the disease; sometimes they even reduce the size of the tumors for a time; but they are not curative.
The only cure is to detect the cancer early–before it has spread and while it can be cured surgically. That kind of detection only happens currently by accident. Absent that, everything we now can do is a holding action that eventually breaks down. When it does, patients die. Their deaths leave a hole in the world of their loved ones.
But to have three successful Phase 3 trials in a year–even if they don’t offer a full-blown cure–I rate that as pretty awesome.
12:45 p.m.
Josh Mailman is a very bright man with a very powerful NET story. Given that we may soon have broader access to PRRT in the US in the near future, his experiences with it may help patients get a better handle on this newer treatment. Watch this 28 minute video on Vimeo in which he tells his story and touches on other pieces as well, including the new Gallium-68 scan.. That will give me time to get some lunch. 🙂
1:30 p.m.
No matter what cancer one encounters,there is a group in the background that is virtually invisible. Attention during an illness is, rightfully, focused on the patient. Very few doctors, nurses, or organizations recognize that when someone in the family has cancer, the entire family has cancer.
And that is true especially of the person who becomes the primary family caregiver. Sometimes it is a mother or father, sometimes it is a husband or a wife, sometimes it is an adult or adolescent child. But is always someone. They are on-call 24 hours a day, seven days a week–and even when they follow the directions that say, “Take some time for yourself,” that time is filled with thoughts of the person they care for.
Sometimes, the cancer story has a happy ending. The caregiver rejoices and life moves forward–though always, I suspect, with the same worry that plagues the darker moments of the patient’s life: “What if it comes back?”
And sometimes the story has an unhappy ending. Then the caregiver stands in the receiving line at the wake or funeral, too numb to really perceive the hugs and condolences that are meant to sustain them. They will feel nothing, most times, until everyone has moved on with their lives.
I put out a call for caregivers to share their stories the same way I put out a call for patient stories. I was not surprised when no one who is currently a caregiver answered the call, nor surprised when only one person who lost a loved one responded. An active caregiver is too busy with the work of staying positive to admit to the trials and frustrations they experience in that role.
And a person in grief after that role has ended is in no state to speak publicly at any length about the bitterness that comes with the end of a long battle that ends in the death of the one they loved.
Pablo J. de la Torre lost his wife Cindy earlier this year to NET cancer. This is his story:
Cindy was being treated at Mount Sinai in New York about a three drive from our home in PA.
I arrived for a visit and found the doctor with Cindy. He had just told us that there was nothing more they could do, Cindy looked at me with a smile and told me she was not afraid.
I decided to transfer her to a hospice in New York so she could be near her family. I would visit every other day or so. I was just amazed that all Cindy was thinking was about my health. It didn’t seem real– I just kept thinking that we would bring her home.
I got ready for a visit early. Just before leaving, I got a phone call from the hospital telling me she had passed in her sleep. I was numb–I just didn’t know what to think. I told my son and we just hugged each other and then jumped into the car for the longest ride of my life.
I don’t remember the trip but walking into the room and seeing her sleeping, peacefully. That’s all I remember of that day.
She passed in May of this year. I did not deal with it– couldn’t believe she was gone.
Now I try to do the best I can to get by. It feels empty in the house, I try to cope and honor her by making sure the support group she started stayed up and strong.
Now I just try to ensure that my children and grandchildren are well and helping them as much as I can. I also try to support friends who are dealing with loss and some who are suffering from cancer.
I can’t say anymore—sorry–it hurts to think.
1:45 p.m.
I understand what Pablo is feeling. When you lose someone you love, everything goes sideways. My father said to me the night Jane died that nothing anyone could say to me was ever going to make this feel any better. He was right. Nothing I do makes that loss any easier to bear.
Just under 10 months after Jane’s death, we launched this website. Four year ago today, I wrote what follows. It reminds me of where my mind was then, eleven months after Jane’s death–and of where my friend Pablo is now.
The beginning of the end began 12 months ago today.
It began quietly enough. We got up early and made the drive to Dana-Farber. The traffic was better than usual because of the Veteran’s Day Holiday. But Jane had had more difficulty getting down the stairs at home. Her legs were often swollen with fluid, but the last couple of days the fluid had begun to build up in her arms again. Her albumin levels, we would learn later that day, were crashing. One of the things albumin does is keep the liquids in the cells where it belongs. Our last appointment of the day was with a nutritionist who was going to help design a diet to boost those levels–and hopefully reduce the swelling.
We had the regular blood draw, then went to see Jen Chan, Jane’s oncologist. We were all concerned about the build up of fluids in Jane’s belly and talked about doing a procedure on Monday to try to draw off some of the fluid. We went to see Javid Moslehi, Jane’s cardio-oncologist. The walk to his office was exhausting and we stopped at a bench about half way there so Jane could catch her breath. I had offered to push her in a wheelchair but she had made very clear she wasn’t going there. Javid was worried about the fluid build-up as well.
We made the trek back to Dana-Farber to have her monthly injection and meet with the nutritionist. The injection was a simple shot in the buttocks. Then we met the nutritionist. She talked about the need to consume more protien. Jane discovered Greek yogurt was full of the stuff–and she loved Greek yogurt.
When the woman left, we were ready to go home. Then Jane stood up. Her pants were soaked through. She was leaking fluid from the injection site. I wanted to get someone to look at what was going on, but she looked at me with those big brown eyes full of pleading: “I just want to go home,” she said. “Please, just take me home.”
Another man might have done something else. For a time after her death I was angry with myself for not being more insistent, thinking that if we had stayed things might have been different. I have since figured out that it was already too late–that there was really nothing I could have done that would have saved her–and that taking her home meant she got one more weekend in the home that she loved–gave us time to say the private good-byes while she could still talk.
The drive home was awful. The traffic was stop and go from Brockton to Taunton. I had to help her out of the car when we got home and carry her up the stairs.
This morning I had trouble getting out of bed. I cried a bit, railed against the injustice of it all, got angry about all the things that made her death inevitable.
And resolved again to find a way to kill this foul disease.
2:00 p.m.
I am still coming to terms with the last days of Jane’s life. On the tenth day of each month I write a piece about her death and the current state of my grief. This month’s piece follows, but I will also post it as a separate piece on the site. It speaks to a significant part of what it means to be a caregiver–the need to keep hope alive in the darkest of times.
Keeping hope alive
Grades closed for the first quarter at my high school five years ago today. I was supposed to finish grading some papers by Friday so I could post them on the computer before report cards were printed and sent out. But I also knew Jane and I were headed to Boston the next morning for another meeting with Jen Chan, her oncologist at Dana-Farber. I was worried about that appointment in ways I hadn’t been before.
…Jane’s body died and took part of my soul with it
Jane’s legs and abdomen were more swollen than they had been just two weeks before. She had stopped going to the basement entirely and the previous weekend had sent me out alone to do the grocery shopping. Neither the long-term Sandostatin nor the multiple daily octreotide injections seemed to be doing much good. But I worked hard not to let her see I was worried. I wanted her to stay optimistic.
Anger explodes
I know now that Jane was equally concerned. She had seen our neighbors a few weeks before–just prior to their departure for Florida for the winter. She’d told them she didn’t expect to be here when they came back. She felt, I think, that she needed to stay positive for me the same way I felt that for her.
I was worried…
I’d spent the previous weekend buttoning up the gardens around the house and giving the lawn a final mowing. As I carried a pile of brush to the composter, my foot went through the sod into a sinkhole. I lost my mind for a few seconds. It made me insanely angry and I let all the pent-up anger and frustration of the last several months boil out of me in a primal scream.
Explaining anger
The anger hadn’t entirely dissipated by the time I came back in. My voice was still strongly tinged with anger when I told Jane what had happened. “Why are you more angry at this than you ever are about my cancer?” she asked. Her own voice was tinged with anger and hurt.
I lost my mind for a few seconds.
So I told her. I was calm about it–completely rational. I told her I was absolutely furious about her cancer–and I was. But I didn’t dare let that anger and hurt and frustration out. I had to stay calm because I had to be able to hear what her doctors were saying to us and understand it. I needed to be able to listen critically to what they told us so that I could ask the questions whose answers terrified us but that we needed to hear.
Caregiver anger
And I told her I was terrified that if I let that anger out some of it would splash over on her. She hurt badly enough, I said. I didn’t want to add to that hurt. “I hate this cancer,” I said. “I hate what it does to you. I hate that it makes you angry–hate that the anger gets directed at me sometimes. But when you get angry with me I remind myself that most of the time it is the cancer talking–and not you–and that if I let myself get angry back it isn’t going to help anything.”
I was absolutely furious about her cancer…
I’d watched her get ready to give herself an injection every morning for months. I’d watched her prep the hypodermic, draw out the fluid, cleanse her belly with alcohol swabs, then push the needle into her body and press down on the plunger. I’d watched her go through the same procedure every night, knowing that earlier in the day she had done the same thing when I was not around.
Bargaining in anger
I could see the marks the injections had left on her stomach. I knew there were ways I could not touch her without causing her pain–even a hug could be too much. And I could see how little good those injections seemed to be. It hurt me in my soul to see all that and know all I could do was hold her hand and smile and whisper constant encouragement.
She hurt badly enough…
There were times, when I was alone, that I looked at the heavens and said, “If you’re going to take her, do it quickly and be done with it.” I felt guilty every time I said that–truth be told, I still do. It’s a horrible thing to wish for the death of someone you love. It feels like the worst kind of betrayal no matter how much it may seem like the merciful thing to do.
Changing the landscape
We didn’t know, as we got into bed that night, that Jane had just a month left to live. We didn’t know that we would sleep in the same bed just three more times. She was, however, smart enough to make sure we said our good-byes that weekend after her heart surgery was set for the following Monday. She told me she fully expected to come home again–that she would not die from this surgery or its aftermath–but just in case…
It feels like the worst kind of betrayal…
A lot has happened in the 59 months since Jane died in my arms. The landscape of NET cancer has changed in some significant ways. Most of it has nothing to do with Jane’s death or my actions since then. Most of it was already in the pipeline. I’m not sure anything major changes in treatment or research if I had just curled up in a ball around my grief and disappeared.
What I might have done
Part of me wishes I had done just that. Perhaps then I would not still find myself wandering the house–moving from room to room aimlessly and watching hours vanish with no idea where they have gone. Perhaps then I would not have a dozen projects lying around me half-finished. Perhaps then I would have done what Jane asked me to do in that long Saturday conversation where we said good-bye.
The landscape of NET cancer has changed…
She told me she loved me; that she wanted me to find joy in life again, wanted me to fall in love again; that she fully expected me to go on with my life. Instead I dream of her last months and of trying to find her when we get separated in a store or in the woods. I dream she is lying next to me–and then wake up to find my arms wrapped around a pillow.
What we did and what I do
Every day, I get up. I eat breakfast. I read the newspaper. I craft a list of things I need to do.
Then I sit down and try to do the one thing I know really makes a difference: work to bring hope to patients and caregivers. Some days it’s comforting patients; some days it’s trying to figure out how to explain the latest bit of science; some days it’s helping caregivers understand what they are feeling is normal; some days it’s helping those who mourn find ways to cope; some days it’s trying to figure out how to raise a few more dollars for research; some days it’s about trying to build structures that will help people when I can’t do this any more.
…I dream of her last months…
Fifty-nine months ago today, Jane’s body died and took part of my soul with it. Fifty-nine months ago today, I stopped being Jane’s caregiver and returned to the work we had always done together: trying to help those who needed what we had to give.
2:30 p.m.
Jenaleigh Landers lost her father to NET cancer 29 months ago yesterday. Today, she offers this remembrance.
Today is Neuroendocrine (NET) Cancer Awareness Day. NET tumors is the umbrella term for a group of unusual cancers which develop from cells in the diffuse endocrine system.
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For those of you who don’t know me/my story as well, NET Cancer is what took my dad from me June 9, 2013. It is an extremely rare disease, but is becoming a lot more common, unfortunately. It is often misdiagnosed for IBS, Crohn’s disease, peptic ulcer disease, gastritis, other digestive disorders, asthma or pneumonia, and by the time NET tumors are uncovered, it is likely that the cancer has spread to other areas—in my dad’s case all throughout the bones in his body. For him, he experienced excruciating back pain, which he thought was due to traveling for work.
NET Cancer does not discriminate… it can affect people of any age, and can be slow-growing or very aggressive. It takes fathers, mothers, husbands, wives, aunts, uncles, sons, daughters, children, grandparents…
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It is the scariest thing I have had to watch someone go through. My dad’s courage was something I admire every single day.
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There’s not a day that goes by that I don’t think of my dad in some way… his last words… last moments… last wishes… all the memories we made together… our plans… what he would think if he saw my brothers and I now.
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The pain comes and goes in waves, and truthfully, I will never be the same. However, his death has shaped me into the person that I am today. I never thought I could deal with such a loss and eventually learn to share the “good” as a result. I miss you every day, Dad, and I will continue to fight your fight for you. Maybe this is WHY you were blessed with such a stubborn and determined daughter.
2:45 p.m.
The bravest people I know are cancer patients–especially those for whom we have no cures. They volunteer for trials, knowing they may just be getting a placebo or the standard treatment; they get out of bed every day and do battle with their disease; they poke needles into their bodies; and so many of them smile as they face things I have a hard time imagining. They are like soldiers going into battle with no weapons other than a positive attitude against a foe who is armed with every advantage possible–but they go anyway.
But there is also a special bravery in the caregivers who walk into that battle with them. When I chaired the local Relay for Life, we made a special lap for the caregivers. It was the final lap of the year. Very few people were there for it. Most people had already packed up and gone home. But it was the perfect symbol for what happens to many caregivers. Their loved one dies, but they have to go on walking–and they often end up walking alone.
If you’d like to add your caregiver story here–or share your experience with grief–I’ll continue to post those stories here until midnight tonight. Just send them to walkingwithjane@gmail.com.
3:00 p.m.
How brave are NET cancer patients? Here are links to two stories that blow even my mind. The first is by my friend Danica, who lives in California. She’s had to have a feeding tube put in–but I’ll let her tell it. Danica’s blog posts will break your heart.
The second story is written by a doctor in Texas. How many liver operations would you take on? Lobster Man probably holds the record.
3:30
Jennifer Chan, who was Jane’s oncologist, and I collaborated four years ago on a pamphlet aimed at patients who were suffering from Irritable Bowel Syndrome to warn them about the possibility that their IBS might really be NET cancer. We’ve revised it periodically since.
What follows is the draft of the next version of that pamphlet. If you know someone with IBS, please share it with them. Do it today.
Is it IBS? Or is it NET cancer?
Irritable bowel syndrome is a common diagnosis for people who are experiencing pain and bloating in the stomach and intestines. It is often caused by eating particular foods or by stress. Avoiding those foods or reducing stress often eliminates the symptoms of IBS.
But there is another disease with almost identical symptoms that sometimes seems to respond to those same treatments: neuroendocrine tumor cancer — NET for short. And unlike IBS, it can progress into something deadly: carcinoid syndrome.
Symptoms:
If you have had:
▪ severe bloating of the stomach or intestines
▪ diarrhea that lasts more than a few days or that recurs frequently
▪ sudden, unexplained weight loss
▪ loss of appetite
▪ frequent insomnia
▪ frequent flushing or hot flashes (a sudden, brief reddening of the body that feels warm)
▪ frequent wheezing
▪ low blood pressure
▪ sudden onset of high blood pressure
▪ redness or swelling of the tongue or mouth
You may have NET.
What is NET?
NET is a relatively rare form of cancer that often starts in the small intestine, appendix, pancreas, and lung. It has also been found in many other places in the body. Truthfully, the tumors can form just about anywhere.
But unlike a normal cancer that can grow very rapidly, NET typically grows very slowly, at about the same rate as the cells in the rest of your body. This slow growth rate may be one of the reasons traditional forms of chemo and radiation therapies don’t work very well on this disease.
Also, unlike most normal tumors, NET tumors take an active role in the body’s chemistry. A neuroendocrine tumor can produce nearly any hormone or peptide the organs in the body can produce. The hormone most often produced is serotonin, but it can also produce adrenaline, insulin or any of a wide variety of peptides or other hormones.
And those extra hormones can produce any of a number of medical problems, ranging from insomnia to heart disease and eventual heart failure.
What should you do?
If you think you have IBS, and/or two or more of the symptoms above, a blood test for chromogranin A, a 24-hour 5-HIAA urine test, and a CT scan may be able to uncover the disease at an early stage. A special kind of nuclear medicine scan called an Octreoscan may also be available in some areas and can be helpful in some cases for localizing neuroendocrine tumors. A Gallium-68 DOTATOC PET/CT scan is a newer nuclear medicine scan available in some locations for the evaluation of NET tumors.
In many cases, if caught at an early stage, surgery can solve the problem before it spreads and does serious damage to other organs. But the tests are not foolproof. There is currently no way to detect this cancer early with certainty.
Still, for this cancer, early detection and treatment is really the only cure.
This story provided by Walking with Jane. Inc., a 501 (c) (3) non-profit dedicated to eradicating NET cancer. For more information about NET cancer or Carcinoid Syndrome contact walkingwithjane@gmail.com or visit our website at walkingwithjane.org.
Each year, I ask Jen Chan a series of questions about NETs and the state of the research. I’d planned to post this interview earlier–right after Ronny Allen’s piece on grading and staging of tumors. But as frequently happens on these Mediathons, I get side-tracked by comments and my own thinking. In any event, here is the interview.
What is NET Cancer? How is it different from other cancers?
Neuroendocrine tumors are a relatively rare and diverse form of cancer that arise from neuroendocrine cells that are located in multiple sites of the body, including the gastrointestinal tract, lung, and other organs. They are characterized by variable but often indolent (or slow-growing) behavior.
One important factor that can affect prognosis is tumor grade. Grade is an assessment of the tumor that takes into account markers of cell proliferation seen by the pathologist on a biopsy. Tumors can be categorized as low, intermediate, or high grade. Low-grade tumors are slow-growing, whereas high-grade tumors are faster-growing.
Neuroendocrine tumors are unique because of their ability to secrete hormones. Most neuroendocrine tumors are non-functional tumors, which means that they are not associated with symptoms from hormone secretion. However, some neuroendocrine tumors (10-30%) produce hormones. Symptoms that a patient experiences will depend on which hormone is produced.
Neuroendocrine tumors, particularly ones that start in the small intestine or appendix, can produce hormones such as serotonin, which leads to symptoms including flushing or diarrhea. These symptoms are referred to as carcinoid syndrome.
Some pancreatic neuroendocrine tumors can also produce a variety of hormones such as gastrin, insulin, glucagon, vasoactive intestinal peptide, somatostatin, and ACTH.
Why is it hard to diagnose? What symptoms should serve as red flags for patients and primary care physicians?
Neuroendocrine tumors can be difficult to diagnose because many of the symptoms are non-specific and can be associated with many non-cancerous conditions. Because neuroendocrine tumors are relatively rare, a diagnosis of neuroendocrine tumor may not be considered.
Neuroendocrine tumors are also hard to diagnose because there is not a widely available screening test, such as mammogram for breast cancer or PSA blood test for prostate cancer.
Symptoms that should lead to consideration of a diagnosis of neuroendocrine tumor include unexplained flushing or diarrhea or unexplained symptoms that are associated with hormone-producing neuroendocrine tumors. Many patients may not have hormone-producing NETs; these tumors are often diagnosed during the evaluation of symptoms, including pain, related to the tumor.
Some patients with carcinoid syndrome can develop carcinoid heart disease. The heart valves, primarily those on the right side of the heart, can become thickened and work less well due to exposure to hormones such as serotonin. Heart failure can develop when the heart valves do not work well, and patients can experience leg swelling, shortness of breath, fatigue.
What is the standard treatment for the disease when it is discovered early? What is the prognosis when it is caught early?
When neuroendocrine tumors are diagnosed at an early stage before spread has occurred, standard management includes surgery. For neuroendocrine tumors that are completely removed with surgery, the prognosis is good, and the surgery is often curative. Some smaller tumors can be removed with endoscopic techniques.
What is the standard treatment for the disease when it is not discovered early? What is the prognosis when it is caught late?
When disease is more advanced, the treatment approach is individualized to each patient and depends on many factors such as tumor grade and extent of disease, organ where the disease started, symptoms related to disease, and how much growth has occurred.
Prognosis will also vary from person to person and depends on factors related to the grade and biology of disease, extent of disease, and the health of each patient. Many patients with advanced low to intermediate-grade disease can live many years.
Regarding treatment options for patients with low to intermediate grade disease:
Treatment options can include systemic therapy, which is treatment that can reach and affect the whole body, or therapy that is directed specifically to where the tumors is located. Systemic therapy can be administered in a variety of ways, such as pills by mouth or injections given intravenously, intramuscularly, or under the skin.
For some patients, surgery to remove all or most sites of disease can be considered.
If surgery is not an option and there is limited disease without any disease-related symptoms, some patients may be candidates for close observation. This is the case since some patients with low-grade disease may have very slow growing disease that may not grow significantly for some time. Treatment can be started at the time of progression or development of symptoms.
For patients with symptoms related to hormone production, somatostatin analogs can help symptoms by reducing hormone production. The medications octreotide and lanreotide are examples of somatostatin analogs.
In addition to reducing hormone production, somatostatin analogs also have been shown to slow growth of advanced gastrointestinal and pancreatic neuroendocrine tumors. Somatostatin analogs are commonly used as an initial therapy for patients with advanced neuroendocrine tumors.
For patients with advanced pancreatic neuroendocrine tumors, systemic treatment options also include everolimus, sunitinib, and chemotherapy. Everolimus and sunitinib are two oral targeted therapies approved by the FDA for patients with advanced pancreatic NET; both have been shown to slow growth in pancreatic NET. Pancreatic NETs can also be sensitive to chemotherapy. Temozolomide and streptozocin are examples of chemotherapy drugs that are active against pancreatic NET.
For patients with predominantly liver metastases, treatment directed at the liver can be considered. Hepatic (liver)-directed therapies include surgery, hepatic artery embolization, or ablation.
We continue to study new therapies for patients with neuroendocrine tumors. Clinical trials investigating new therapies may be an option for some patients with advanced disease.
For patients with advanced high-grade, poorly differentiated neuroendocrine carcinomas, platinum-based chemotherapy is often used.
As the disease progresses, what kinds of things do patients experience, physically and mentally?
For some patients, there are no symptoms even when CT scans or MRIs show tumor growth.
For some patients, however, there may be development of symptoms such as fatigue, loss of appetite, weight loss, or pain. Some patients may experience an increase in hormone-related symptoms if there is an increase in hormone production that correlates with disease progression.
Disease progression can also be emotionally challenging. Depression might occur. Patients benefit from the support of family, friends and their health care team. The health care team can consist of many individuals, including oncologists, nurses, social workers, psychiatrists and therapists, and nutritionists.
What is the greatest challenge we face in dealing with this disease? From a patient standpoint? From a medical standpoint?
From a patient standpoint, it can be challenging to find a team of health care providers with knowledge and expertise in managing NET. A multidisciplinary approach is critical to the care of patients NET since NETs are a diverse group of tumors, and our approach needs to be individualized. Depending on the situation, there may be a role for surgery, interventional radiology or nuclear medicine techniques, or medical therapy. When to start and how to sequence therapy may also need to be decided. These are complicated issues, and it is helpful to have multiple people thinking together about each patient.
From a medical standpoint, education and raising awareness about NET remains extremely important. With early diagnosis and intervention, we can hopefully cure more patients and improve outcomes. It is also critical that we expand our treatment options for patients with advanced disease. Compared to many years ago, patients with NET are now living much longer. However, we still need better treatments to control disease and help with symptoms related to disease so that patients can live long, productive lives with good quality of life.
How have things changed with NETs over the last year? What do we know now that we didn’t know then? How has that knowledge changed what you are doing both with patients and in the lab?
In September 2015, the results of three large randomized placebo-controlled trials related to neuroendocrine tumors were announced. All three had positive results that are practice changing and will expand possible treatment options for patients with NET.
1) The TELESTAR study was a randomized study of telotristat etiprate, an oral agent that blocks the activity of tryptophan hydroxylase – the rate limiting step in the synthesis of serotonin. Telotristat was associated with reduction in bowel movement frequency in patients with uncontrolled diarrhea despite standard doses of octreotide. 24-hour urine 5-HIAA levels were lower in patients receiving telotristat – indicating effective inhibition of tryptophan hydroxylase and reduction in serotonin production due to this agent.
2) The RADIANT-4 study demonstrated improved progression-free survival with everolimus in patients with advanced non-functional NET of lung and GI origin.
3) The NETTER-1 study demonstrated improved progression-free survival with the radiolabeled somatostatin analog 177-Lu-Dotatate in patients with progressive mid-gut neuroendocrine tumors.
The results of the RADIANT-4 study and NETTER-1 study are particularly exciting and promising because historically, patients with advanced non-pancreatic neuroendocrine tumors have had limited systemic treatment options. Both of these studies show that growth can, in fact, be slowed and will expand possible treatment options for patients with NET.
There’s been a lot of talk about immunotherapy this year–and one foundation just made a grant to some researchers to look at using it in NET cancer. Can you explain what immunotherapy is? Is there cause for optimism about its use in carcinoid/NETs?
Immunotherapy is treatment designed to enhance the immune system’s ability to recognize and attack cancer cells. The outcomes of patients with some forms of cancer, such as melanoma, have improved dramatically through the use of immunotherapy.
Given the favorable results and advances that have been seen in other tumor types, it is important for us to understand the immune characteristics of neuroendocrine tumor cells and to investigate the role of immunotherapy in the treatment of NETs.
What is the most promising thing you see on the near horizon?
Several large clinical trials investing novel treatment approaches have recently been completed. We are awaiting the results of these studies, all of which have the potential to influence treatment options for patients in the future.
Recent translational research has also provided new insight into the biology of neuroendocrine tumors. For example, a recent gene sequencing study suggests that dysregulation of the cell cycle may be important in the etiology of small bowel NET. As we understand more about the factors that drive the development and growth of neuroendocrine tumors, we hopefully will be able to find new targets for therapy.
Additional research also needs to be done to better understand why some people do and do not respond to certain therapies. Results from this investigation may help us to select the most appropriate therapy for each individual patient.
4:45 p.m.
The Carcinoid Cancer Foundation is doing a live chat on Twitter that I just remembered was there. Follow the #NETCancerChat to see what is going on there.
I’ve been running as hard as I can with my head down all day. We’ve posted over 15,000 words–not counting the posts we’ve sent people to since 6 a.m, this morning. I just went out for a few minutes, figuratively speaking, to check on what else is going on in the social media universe having to do with NETs.
It’s a jungle out there. More than half the posts on my regular Facebook page are about NETs–and while I’m not seeing as many Zebra-themed profile pics as I’d like, the content of posts is certainly making up for that.
I have more patient profiles to post, some bits on the NET Research Foundation and the Carcinoid Cancer Foundation, a couple more videos to share, and one major announcement about a new project I am holding of on until prime-time. Do people have suggestions about where they’d like to go next? What other kinds of things they’d like to see? You can comment here or drop a line to walkingwithjane@gmail.com. A PM would work as well.
What’s your pleasure, folks?
5:oo p.m.
Linda’s story of her diagnosis is too familiar to anyone who has been around this disease very long.
What is your name? Linda
Where are you living? Cincinnati, OH, USA
Describe how you found out you had NETs.
I had Multiple Pulmonary Embolisms in April 2008. The next month, and several more times that year, I made additional trips to the ER because I was short of breath. I was told at each of those visits that I did not have any more embolisms and was treated for Asthma.
I was 54 years old that year and had never been diagnosed with Asthma. Also, I had never been short of breath like that. In December, after yet another ER visit, I was told that I had lung nodules. They had been seen on my first chest CT in April 2008 and was finally given a referral to a pulmonologist.
The pulmonologist was not worried about the nodules because they were small. Also, not many doctors in this area have met anyone with Lung Neuroendocrine tumors. Current protocol has been that there must either be persistent growth on two sequential CT Scans or the nodule is greater than 1cm (10mm). As my CT Scans were just a few weeks apart and my nodules were initially 5mm and 8mm, they were not considered to be of any consequence.
What problems did you have getting the right diagnosis?
After three years of waiting for someone to figure out why I suddenly had asthma, I started researching the possibilities in PubMed. As a U.S. military and college trained Information Technology person, my first thought was to do a spreadsheet of all the CT Scans that had been done. Eureka! There was the answer. Very, very slow but steady growth that appeared to follow the guidelines for Neuroendocrine Cancer.
I then contacted yet another pulmonologist who, very excitedly, agreed that my spreadsheet did, indeed, indicate that there was growth. Further testing concluded that I had Atypical Cells with Neuroendocrine Features and so the first VATS was scheduled.
When were you diagnosed? November 2012
What problems does your NET cancer create for you?
I still have pain from the first surgery that has slowed me down quite a bit because it is not very well controlled. I am on Gabapentin. I have also been using either an Ace Bandage or a heat wrap designed for lower back pain wrapped around the lower part of my lungs on that side.
What is your typical day like dealing with NETs?
I try to do as much as I can as quickly as I can because I know that when the pain kicks in, I will not be able to do any more. The pain takes my breath away and also wears me out. Unfortunately, this is not the only health issue I have. It does make it complicated for the doctors to treat me.
What treatments have you had?
I have had two surgeries to remove three tumors in my lungs. The first one was in November 2012 for a Left Upper Lobe Wedge Resection via VATS to remove two tumors that were 7mm each. The other surgery was this past March to remove my Right Middle Lobe to remove the 1.4mm tumor there. The tumors are not considered metastatic because they were all seen on the initial chest CT scan in April 2008 and were small. So, I have been diagnosed as being Multi-Focal or Multi-Synchronous.
Did they work for you?
I am currently considered to be NED (No Evidence of Disease). There has never been any sign of anything other than the three tumors that were removed. I am somewhat lucky compared to so many others because these tumors were found accidentally and while they were quite small.
What kinds of side effects have you experienced from treatment?
The only bad side effect has been the pain. The big benefit is that I am only short of breath when I try to push through the pain. The Asthma is completely gone. In fact, it has since been diagnosed as Carcinoid-induced Asthma.
How does where you live affect your ability to get treated for NET cancer?
I am near Markey Cancer Center at the University of Kentucky where there is a Neuroendocrine Cancer Team. http://ukhealthcare.uky.edu/markey/neuroendocrine/ I have been seeing Dr. Edward Wolin this past year, but he is moving to New York and so my care will be transferred to Dr. Lowell Anthony. Prior to this, I had seen Dr. Eric Liu one time at Vanderbilt University, but he is now in Denver, CO. So, I have been very lucky to have been and continue to be seen by NET Specialists since my first surgery. Unfortunately, there is not a Neuroendocrine Cancer Team here in Cincinnati with the experience that these physicians have.
What is your biggest frustration?
My care is spread between my doctors here in Cincinnati and in Lexington. Since I have multiple health issues, I see a pulmonologist, an endocrinologist, a gastroenterologist, a neurologist and my primary care doctor here. I see the thoracic surgeon and the NET Specialist in Lexington. This means that I have to carry copies of my records between the different doctors. It also means that there really isn’t much communication between here and there. However, I know that I am very lucky to be able have the benefit of the experience of the NET Specialists that I have seen.
5:15 p.m.
Some pure, blue-sky speculation follows. This is probably a stupid question, but then only stupid people don’y ask stupid questions.
Something has been bothering me for a long time that this story reminds me of. Many NET patients have more than one serious illness going on–and some have several. My mother-in-law died of pulmonary fibrosis, a supposedly rare disease. Yet I know several NET patients who have pulmonary fibrosis. And I know more than one NETpatient with MS.
That seems peculiar to me. It may be coincidental, of course. I haven’t done the statistics to tell me how probable either case is–I’m not sure my math skills are up to the task in any event. And no one would listen to me if I did the statistics–I am, after all, an English major. But maybe someone should think about this.
5:45 p.m.
The Caring for Carcinoid Foundation has a new name this year and a new website. They’ve always been very professional in their approach from what I’ve seen. Their new logo and website design underline that professional vision. They are now the Neuroendocrine Tumor Research Foundation–or the NET Research Foundation for short.
They are currently funding the trial of an immunotherapy drug for NET patients. It is an expensive, but important undertaking.
Ron Hollander is their director. He asked me to post this release he sent me for NET Cancer Awareness Day.
Each year, the greater NET community uses NET Cancer Awareness Day to raise awareness about NETs and the need for timely diagnosis and access to optimal treatment and care. The NET Research Foundation is proud to be a member of the Board of Directors of the International Neuroendocrine Cancer Alliance (INCA), which is coordinating this effort worldwide.
In honor of NET Cancer Awareness Day, we are highlighting our commitment to making a difference and transforming the landscape of neuroendocrine cancer research. We have proposed major initiatives to shape our project portfolio and push research progress to new heights over the next year. We have been purposeful to direct our research initiatives to produce results to understand how neuroendocrine tumors tick and how to defeat them. We are committed to:
Understanding tumor biology to discover possible biomarkers, targeted treatments and tools for earlier diagnosis;
Building a strong bench of committed researchers through grants and awards to support young investigators and emerging research talent;
Leveraging exciting developments in cancer immunotherapy and potential targeted therapy breakthroughs in other cancers, and bringing the leading techniques and experts to the work to control and cure NETs;
Providing objective, valid and actionable information and guidance to patients and families dealing with neuroendocrine cancers.
Help us spread the word about NET Cancer Awareness Day to give hope for the future to patients suffering from neuroendocrine cancer. Visit our new website to learn more about our impact on NET research.
And let me tell you, the new website is cutting edge. They group has been very good to Walking with Jane from the time we started to now. If you want to support their research, you could do much worse. I send them what I can every year.
Among their projects is an immunotherapy initiative that is really interesting and has enormous potential to make a significant difference. It is the only idea I see being actively pursued that has curative potential.
6:30 p.m.
Sorry for the unannounced extended break, but it occurred to me as I finished that last post that I was feeling a might peckish. Then I released that I’d had a bowl of cereal and glass of OJ about 5:30 a.m., a tuna salad sandwich and some grapes around 1 p.m. and had barely moved from the chair I’ve been writing in most of the day.
Do I fixed myself some dinner and am now ready to confront the final 5,5 hours of this excursion into the underbelly of NET cancer and the dark recesses of my mind. I hope more than a few of you will hang around for the night–and that you’ll all recruit a few more likely listeners to help the next few hours feel less empty.
Let’s meet Angie, next. She’s a 46 year old patient from Des Moines, Iowa.
I was diagnosed with neuroendocrine carcinoma in Feb after having about a week of dull, but annoying pain in my right abdomen area, and “self diagnosing” a gall bladder issue. An ultrasound ordered by my family doc showed “multiple lesions on my liver.”
She referred me to a local oncologist and I had a liver biopsy a few days later. I also sought a second opinion at the Mayo Clinic and they agreed with the diagnosis.
A typical day for me very much depends on where I am in my chemotherapy cycle, since this is my only treatment option so far. In March I began getting Cisplatin & Etoposide chemotherapy every three weeks. Side effects were mainly fatigue and taste issues, very little nausea, I lost my hair, and by round four we stopped this combination because the Cisplatin caused severe hearing loss/ringing in my ears. I now wear hearing aids.
This was followed by two rounds of carboplatin & Etoposide. CT scans were done every two rounds and tumor shrinkage was shown with each scan. I took about ten weeks off from chemo after that, went back to Mayo to see a different doc (a true NET specialist), then started having some pain again.
I then started a new chemo combination of taxol & carboplatin and am on round three. Taxol is nasty! More fatigue, some nausea, very uncomfortable muscle/joint pain, neuropathy in my feet. It kicks my butt for about a week, then I start to feel great (which I’m very grateful), just in time to get ready to do it all over again!
I actually feel very lucky that I was diagnosed quickly, even though mine is high grade and fast growing. I love my local oncologist and feel fortunate to only be three hours from Mayo and about an hour from the University of Iowa hospitals.
My biggest frustration has just been the confusion associated with this cancer, trying to learn all I can, hoping I’m making the right decisions about treatment, and just knowing it is treatable but not curable.
6:45 p.m.
The Carcinoid Cancer Foundation is likely older than all the rest of the NET cancer foundations in the US combined. It was formed about the same time the federal government decided funding what was then called carcinoid cancer was not cost effective. For four decades, they were pretty close to the only game in town for funding research or raising awareness about NET nationally.
They seem more focussed on awareness and patient support than on research at this point if you look at their website. But they do an exemplary job at those two things. They fund patient conferences where lay people can find out the latest NET information, help people find the nearest doctor who works on NET cancer, provide support groups and other resources. They know their stuff–and they are on my very short list of NET cancer groups I give money to.
Patients would be lost without them. But they also provide information and support for doctors trying to help patients get through the mess that is NET cancer.
They, too, were very supportive when I started working on Walking with Jane. They helped us set up interviews for our first big NET cancer awareness project back in 2011–and when i have a question, Grace Goldstein, their director gets back to me with information worth its weight in gold. Again, if you have money to donate, this is a good home for it.
7:00 p.m.
There are a number of other small foundations working on NET cancer. Honestly, none of us are in the same league with either the Carcinoid Cancer Foundation or the NET Research Foundation. We simply don’t have their experience, their staff, or their national reach. Any one of us could likely piece together a regional conference if we needed to and have one or more of the big names who will answer our phone calls or emails.
But small as the NET community is, pulling in a significant group of national figures is well beyond what Walking with Jane could pull off. And I’m not sure how much else we could do that year beyond that effort. Walking with Jane is really largely a one person operation that can call on a good-sized group of volunteers for a few hours every month. But if letters are going to get written or posts get made or posters designed, that largely falls on me most of the time.
And I suspect most of the rest of us are in the same boat. We are doing what we can, but our fundraising reach and real areas of influence are regional, not national or international. I suspect we all aspire to be national or international in scope on down the road, but we are not there now.
And I have to admit, I find the process wearing. I don’t like begging for money. I don’t like spending all day every day confronting the disease that killed my wife. I do it because it needs doing–not because I enjoy doing it most days.
I do like learning new things. I like the fact I’ve had to n]master a number of new skills. And I know that it prevents me from lying in bed staring at the ceiling and wishing Jane hadn’t died and imagining the life we might have had–all of which would depress me more than words can say.
7:15 p.m.
Late last year, shortly after NET Cancer Day, I took a good hard look at the NET cancer universe–not as a doctor or researcher–but as a marketer and organizer. I wrote a series of posts in which I argued for a whole range of ideas about how we could make the landscape better for researchers in terms of resources by rethinking how we were approaching what we were doing.
At the end, of that process, I wrote up a collection of goals for all of us working on the NET cancer funding and awareness problem. Much of what I wrote fell on deaf ears, I suspect–but a lot of people read those ideas and thought about them. At least I hope so.
One of the things I suggested was that each of the smaller foundations adopt a NET cancer center in its region to develop support for. Late last summer, Dana-Farber came to a similar conclusion about needing to put together a group to better support its Program in Neuroendocrine and Carcinoid Tumors. We held an initial meeting in early September that included Matt Kulke, who directs the program, Hillary Repucci from the development office, a patient with a business background, and me.
Matt had put together a presentation about what the program could do if it had the resources to do it. We take about a range of issues and I came away with a real positive feeling, in part because Matt was talking about exactly the same idea I’d hatched myself 10 months before.
7:45 p.m.
By now, you’ve figured out that I have a special relationship wth the Dana-Farber Cancer Institute and its Program in Neuroendocrine and Carcinoid Tumors. If you are a regular on walkingwithjane.org, you know how tight Jane and Jen Chan were from the start. And you may remember that, periodically, Jen and I sit down and have a good cry over our loss of Jane.
I am not one to put all my eggs in one basket–thus my ongoing support of the Carcinoid Cancer Foundation and the NET Research Foundation. But the lion’s share of my effort finds its way into the DFCI coffers when all is said and done.
And my support is not based purely on an emotional response. DFCI’s fingerprints are on one of only two NET cancer cell lines ever developed, on all three of the drugs at the top of the NET treatment list, and on a couple of other things as well.
The fact they are only 50 miles from my front door doesn’t hurt either.
So after our early-September meeting, I drafted a plan for what such a group might look like and do. I doubt the entire plan will ever be adopted–its scope is likely too large to really work the way I’d like it to; and it is a bit scary even to me looking at it now. But basically, it called for a team that would work like a high-powered board of directors–though without that kind of management authority. Each member would chair a subcommittee with a specific charge.
I reproduce that set-up here as a thing for others to think on in the hopes it will spark at least some conversation–and encourage through a concrete example the kind kind of thing I was thinking about last winter.
The group would be structured into the following sub-committees:
Steering Committee. This group is charged with planning the agenda for team meetings and overseeing the work of the various other committees. Membership should consist of the team chair(s), the head of the program (Matt) or his/her designee, other team officers—co-chair, secretary, treasurer (?), and the person from development responsible for the Program (Hillary).
Major Donors Sub Committee. This group is responsible for cultivating potential large donors, both corporate and individual. The group should create at least one presentation/slideshow for major donors. The chair or co-chairs serve as ex officio members of the committee. Hillary should be part of its meetings, as should someone from the Program.
Annual Giving SC. Create and maintain a list of smaller donors and develop an annual campaign based on letters and a mass mailing. Develop other methods of reaching this group. Perhaps this group should have as part of its charge running the Marathon Walk team.
Event Planning SC. This group is responsible for planning fundraising dinners, tournaments and other events. It may also plan awareness events in conjunction with the Awareness SC below. We should aim to develop at least four significant fundraisers each year. These might include developing teams for the PMC, Jimmy Fund Walk and Boston Marathon. Hillary or someone else from development should be a member of the committee. The chair or co-chairs serve as ex officio members of the committee.
Priorities and Critical Needs SC. This group exists to lobby within DFCI for such needs and priorities as seem important. For example, we should be taking steps to make the octreoscan and the Gallium 68 scan available to our NET cancer patients. I agree, this committee should not be raising money for these, but we need to argue effectively within DFCI for these kinds of things. It could also press for more people on both the clinical and research sides of the equation. Matt or his designee should be on this committee. The chair or co-chairs serve as ex officio members of the committee.
Awareness SC. This group works on creating general awareness of NETs both among doctors and patients. It is charged with organizing a lay conference and a conference for PC doctors—perhaps on an every other year basis. It should also create and distribute pamphlets about NETs. (I have one in hand and could easily create a second.) The chair or co-chairs serve as ex officio members of the committee.
Science SC. Reviews the science and advises on what pieces of research would be most useful to report on to the larger group. Looks for synergies in the global research that further research could exploit. The chair or co-chairs serve as ex officio members of the committee.
Communications and Public Relations. In addition to cultivating media contacts and organizing press focussed events, the group puts the latest research into laymen’s terms. It also works on public service announcements for various media. It should create a November 10 package of stories in several media for NET Cancer Awareness Day in conjunction with the Awareness SC. It should develop a speakers bureau and actively market that to the various civic organizations: Kiwanis, JayCees, Lions, Elks, etc. It should have a representative from DFCI’s communications group involved. The chair or co-chairs serve as ex officio members of the committee.
These groups meet as needed, but at least quarterly. The majority membership of the subcommittees should likely not be people on the Program team.
Other things we need to think about:
Develop a Sustainer model for annual giving.
Explore ways to use the Jimmy Fund Radio Telethon to raise awareness of both the disease and the Program.
Examine our current program for patient advocacy and support to determine whether the services we offer are sufficient and how they can be improved. What do patients and caregivers need that we are not currently offering? Perhaps this should also be a standing committee.
8:00 p.m.
We arranged for several potential members of this group to sit together at the Annual Visiting Committee Dinner in late October. There seemed to be some interest in pursuing the general idea, although the detailed structure outlined above was not raised.
In December, we will pull together a somewhat larger group of potential members. We are in the process of discussing who to invite and what the agenda for that meeting should look like. We’ve also had some discussions about potential goals for the group.
Over the next week or so, I will begin putting together a draft slide-show for the group for that meeting.
We’ll see how this evolves and where it goes.
And that, friends, is the major announcement I teased late this afternoon. What do you think? Is this a potential model for other NET cancer centers?
Hillary, I hope I haven’t gone too far here.
8:15 p.m.
Jillian is a member of our Marathon Walk team. This is her story.
How I found out I had NETs: I began flushing one day after breakfast. It was mostly after eating, but there were other times of the day that it would occur as well. One day, it just appeared out of the blue with no other symptoms.
It took a handful of doctors across two states before I had a diagnosis. Doctors said everything from, “drink more orange juice” (thinking it was blood sugar related) to “you can’t have NETs because you don’t fit the profile.” Even when my tests were coming back positive, it took scans for some doctors to actually believe it. One doctor dismissed the possibility simply because he said it was rare and he had never seen a case.
When were you diagnosed: fall of 2008
Problems NETs creates for me: I have to be careful not to get myself in really stressful situations because such situations elicit syndrome symptoms for me.
For treatment, I get monthly shots of Sandostatin LAR. I had major surgery in 2009, and I had two chemoembolizations done early this year. The treatments have all worked for me. Side effects from the chemoembolizations were nausea, vomiting, weight loss, severe back pain.
How does where I live affect my ability to get treated? Currently, living in New England, I have easy access to Dana-Farber which has been really nice. Previously, when I lived in Hawaii, it was really problematic. I had to fly to the mainland for my surgery.
My biggest frustration: Lack of control. I’m a go-getter and I feel like I can’t really be that in person right now. I worry that I’ll have a syndrome flare up if I get at all stressed.
8:45 p.m.
Patient stories with this disease are frustrating. Doctors don’t see it–and even when they do, the deny it. They don’t want to believe what the tests are telling them–and I don’t understand why. For example, I give you Jacquie Prevette
I have been diagnosed with metastatic pancreatic neuroendrocrine cancer. I am married; the proud mother to 3 very lovely daughters, and Nana to 13 (the youngest is 3 months old). I would give ANYTHING just to be able to dance at my youngest grandchild’s wedding.
My story begins with a different type of cancer, Clear Cell Renal Cancer. It was during the removal of the Kidney cancer that the surgeon located a small tumor in the mesenteric. My family and I were told it was nothing to worry about. This was July 2013.
It was not until my first visit with a local oncologist that I realized this was something I needed to research.
At the time of my cancer diagnosis, I had been a caregiver to my twin who has metastatic rectal cancer. His care took most of my day. So it took a while to find information on the website.
After a year, I finally suggested to my local oncologist that I probably needed some standard testing done…My Chromagranin A was through the roof, but other tests (blood and various scans) have came out negative. My local oncologist was happy with those results and didn’t want to see me for another year.
After more researching and traveling from IL to TN and then from IL to IA (sometimes by myself), I have found a doctor that understands the disease. I am not sure I am with the doctor I need to be with…there is one in CO that was the first doctor that I found on the internet that helped me to understand this disease a little better.
For me, the worst part of having this disease has been the fact scans have not been able to locate the primary tumor. It is my understanding that my prognosis is way better if they are able to remove the primary.
I do not have all the symptoms of Carcinoid Syndrome…I do have multiple bowel movements that limit my activities. Sometimes depression sets in…not the kind where I want to end my life. The complete opposite really.
I am at my heaviest weight; have constant pain around the pancreas area through the back; extreme GERD; and sometimes nausea.
Sometimes it is very frustrating to feel so awful…but look fine. A lot of people I care about do not understand. At times I feel they do not believe I have cancer at all. I am scheduled to have the Ga-68 scan the beginning of the year. This scan will cost $6k..but if the tumor(s) are located, it is well worth it.
On another note, I have found a new local oncologist…but I have to drive 45 miles to visit.
9:00 p.m.
Here’s a short video on telotristat etiprate that was made before the release of the latest study. But it does a good job of explaining the process of all the trials that have put the drug on the edge of FDA approval.
Here is a really good explanation of NET cancer from the Royal Free Hospital in London. I’ve seen a lot of these in the last five years, and this may be the best I’ve seen in terms of making the disease clear to a lay audience. The guy is really good. It is a bit long–a little over an hour–but the man is entertaining as well as very knowledgeable.
10:15 p.m.
High grade aggressive NET is about as bad as things can get. There is no such thing as a good NET as far as I’m concerned–but this type is really awful.
Hi my name is Angie. I live in North Huntingdon, Pa., a suburb of Pittsburgh. I was diagnosed with Stage 4, High Grade Neuroendocrine Carcinoma on Oct 4th, 2014. My life has not and will not ever be the same.
For over 10 years my health status was declining. I had a hystectomy because of fibroids, endometriosis and painful menstrual pains. B-12 and D3 vitamin deficient, wheezing and other respiratory issues, Rynauds Syndrome, diverticulosis, diverticulitis, polyps, increased B/P, palpitations, flushing, diarrhea, constipation, night sweats, insomnia, sleep apnea and increased anxiety because of all these health problems.
My PCP could not think outside the box. Every time a health problem would arise, I was sent for more testing and sent to more specialists. Just another diagnosis added to the list of many.
On Oct 1st I decided to go to the ER. My stomach was distended and my right leg was triple the size it normally is. For 2 days of testing, scans, a colonoscopy and a liver biopsy. The pathology report came back. We knew it was NET but there are various levels of NET.
On the night of Oct 4th, my Oncologist came in to talk with my Husband and I. He said it is not the scenario that we were hoping for. You have Stage 4 High Poorly Differentiated Grade Neuroendocrine Carcinoma(NEC). It’s aggressive, rare and there aren’t many options. Chemo and radiation are the options. You can’t have surgery because in the time it takes for you to heal, you will have even more tumors every where. My Husband and I cried, we held each other and wept. These weren’t the answers we wanted.
It took me a few days for the news to sink in. I decided at that point that I will stay POSITIVE! FIGHT this cancer with everything that is inside of me. GOD is in control, not these doctors!
It’s been a year of three different kinds of chemos. Two months in the hospital, pain, fatigue, neuropathy, pulmonary embolisis and dehydration. The tumors have responded somewhat but my liver tumors have doubled and I now have Mets to my brain. I had radiation on Friday.
I’m not with the same Oncologist that I started with. No disrespect, but he wasn’t a specialist. I’m at Hillman Cancer Center, in Pittsburgh. With a Specialist that was recommended by a surgeon that was recommended. They have no other ideas than what we started with. I was told last week that I have one more chemo to try and that is it. This is NOT acceptable to me!
I researched NET specialists. None of them specialized in NEC. Until finally, I found a NET specialist that also specializes in NEC. He’s a “Rock Star” He has practiced all over the world. He has doctor privileges every where. He is the BEST!
My Husband and I flew across the United States to meet with Dr. Eric Liu. I was told he was booked for months but because of the severity of my case they would see me.
Yesterday I had to drop off all of my medical reports and Cd’s. The atmosphere at Rocky Mountain Cancer Center was calm and tranquil. Everyone we met was very helpful. The Dr. Liu’s, administrative assistant, Doni, has been amazing. He met with me yesterday and he could tell I didn’t feel well. He went and got Dr.Liu’s RN, Pam. She assessed me and my vitals. We both knew I was in crisis.
We talked about when this happened before and she just relaxed me. We went to Dr.Liu’s office. Dr.Liu came in. “Good job on Pittsburgh winning!” What?! He already knows me! He told his RN to have my Sandostatin shot authorized by my insurance because it was due to be administered in a few days. Dr. Liu is a very kind, compassionate, brilliant and humble man. I can’t wait to sit down and discuss what options are in the toolbox still. My appointment is tomorrow.
Through this fight I have stayed positive! Attitude is a EVERYTHING! I have been blessed with the very best support system, my friends! The number one thing in my life is GOD! He has a plan for me. I have to be obedient and follow his path for me. LIVE like it’s your last day! Laugh until you pee your pants! LOVE with all of your heart!
Today is NET awareness day! Every day should be NET awareness day! “IF you don’t suspect it, you can’t detect it” My case is rare. If I would have been diagnosed sooner, my life would have been different. Please EDUCATE and be AWARE of this disease!
Thank you for reading my story. God bless you!
10:30 p.m.
Don’t ask me how I’ve managed this, but despite having posted more than 6000 words more than we did a year ago and several more and longer videos, we are still 90 minutes from midnight. I have a couple things left, but without some help in terms of comments and things to play off of, this next hour and a half is going to be a little tricky.
Next year is 12 months away, but I’m already thinking about how to make things better. I hope that next year we will find a way to go 24 hours rather than 18. One way to do that is to recruit some folks in other time zones to take on the first six hours.
I’m also thinking a co-host–or having a number of co-hosts join me over the course of the day–would liven things up. As I’ve noted above, having someone responding to what I’m saying and doing helps keep things moving, We had some of that early in the day, but far less of it tonight–and it makes a difference–especially in these final hours when I’m beginning to have trouble piecing words together. My typing skills also seem to decline the closer we get to midnight.
If you think you might be interested in helping out next year, let me know.
10:45 p.m.
Vicki Harris Living in Duncanville Tx. I was diagnosed after being in the hospital with Pneumonia. Going on 3 years ago I was diagnosed with A-typical Lung Carcinoid. I am still trying to get care. I am without any insurance. My typical day includes worrying about how to get care. Now having bad bone pain, so really concerned.
I don’t have a lot of symptoms right now. Some wheezing. Get tired easy. But now I’m having severe pain on the side of my hip. Can’t walk good. Getting worried about that.
Vicki’s story raises an issue I went into a lot of detail about a year ago–and then discovered that what I was being told by some organizations was true wasn’t.
This year, not a week goes by that I don’t get a post from someone asking for help funding their cancer treatment through a gofundme or similar account. I know from talking to many patients that Obamacare was an improvement over the little or nothing they had–just getting rid of pre-existing conditions language helped. But too m any people are still without health care.
I know some folks will accuse me of being a socialist, but I don’t care. The longer I deal with cancer patients the more I am convinced that national health is an idea whose time has come. A month’s supply of octreotide was $58,000 in 2010. A single Sandostatin LAR injection today runs about $10,000, depending where you are.
Jane and I were fortunate enough to have really good health insurance. Knowing what we spent on her care the last four months of her life, I know I would be living on the street if I’d had to pay all that–or even a significant fraction of it.
Something to think about.
11:00 p.m.
I recorded this two years to explain why I do what I do. How I feel hasn’t changed in that time. The good news is some things are changing that mean the outlook for others is getting better.
11:15 p.m.
Ronny Allen really does a great job of talking about his experiences with the disease. If you want a site to subscribe to. Ronny’s is one. Here is another of his clear posts about the fundamentals of the disease. It serves as a good review of some of the major things we’ve talked about today.
11:30 p.m.
So here we are, coasting to the close of another NET Cancer Awareness Day on the East Coast of the United States. My neighbor are sleeping and many of those who started the day with us at 6 a.m.–especially those in Europe–are as well.
Every year at this point there is a bit of depression in my soul. I look at the numbers–the number of words posted, the number of comments and likes, the number of people in the audience–and I wonder whether all the stress and effort was worth the trouble. Did we reach enough people–make substantial differences–or even small differences in their lives.
I know one patient who understands her husband better because of one piece of today’s work. I know a couple of caregivers who are relieved to discover they are not monsters because of the anger they sometimes feel.
And I know there are some patients and caregivers both who learned about a new treatment or two that are not in the too distant future. They have renewed hope that the dream of seeing a son or daughter graduate or get married isn’t as unrealistic as they thought was when the day started.
But I wanted to do more today–wanted to discover more. I had hoped to be reporting on the Uppsala virus in some way, shape or form. But that cancer-eating virus seems to have slipped beneath the waves of a distant fjord without sound or notice. Maybe next year.
11:45 p.m.
I’d also hoped for more information on immunotherapy. I’ve heard a single whisper on that–and everything in that whisper was contradictory. It will either work or it won’t. For now, I’ll view at as a deep pass that is still in the air. It may prove to be a touch down–or it may fall incomplete. Five tears of watching and waiting have brought me to a point where neither the possibility of success nor the possibility of failure gets me very excited.
I want to thank everyone who helped today–and there are dozens of you–from the ones who simply said thank you to those who wrote things to those who passed along links and videos. I get to play front man today, but none of this exists without the many of you who take the time to read what I write and those of you who let me borrow your words and work.
People tell me that Jane would be proud. I don’t know whether she would be or not. I disobey her last requests every time I run into this wall that is NET cancer. I just know that I am doing the best I can in the tradition we both observed–embracing the good of the many.
Walking with Jane raised no money today. That wasn’t part of the plan. But I know we raised some spirits today and gave some people some hope. That’s the thing that really matters.
I’ll be back in just a few minutes with tonight’s final numbers. See you then.
11:58 p.m.
We did well today, according to the metrics. Our total audience was well over 6000 once all the numbers from the various site were added up. walkingwithjane.org had 526 visitors from ten different countries. We generated over 700 likes and comments.
I’ll let our last commenter have all but the last word here tonight. This is from Linda, commenting on the caregiver piece.
I know most caregivers do not want to discuss what they go through, including my husband. But, I see him sitting hour after hour in the most uncomfortable chairs ever created just to be with me. He has his own health issues. But, he keeps putting my care before his. Even when I keep nagging, he will only take care of himself after he is sure that I’m ok.
As I read what you are doing, I see him. You are a very compassionate person. I see where you have done much of the same through all of those long waits in ERs, surgical waiting rooms, doctor’s offices, and all of the different types of testing we go through. We go to sleep and wake up confident that the one we love most will always be there. It gives us the strength to go on when we find it to be difficult.
So, we all thank you for continuing to support the fight!! In many ways yours is the more difficult part of this battle.
