Thursday, July 28, 2011

Update - sort of

With the end of the Tour de France and my ongoing wait for a spot in the clinical trial, I thought I would take time to catch you up with a random collection of facts and observations I have not been able to tie into any narrative thread, but feel important to share.

•  I've recently adopted a very short haircut, in part to externalize my fighting spirit and partly to cover up the result of radiation therapy.  Thankfully, my hair did not fall out from the chemotherapy.  However, it did disappear along the side of my head where the radiation beam went through my eye socket and continued on to China.  So I wear my hair short these days waiting for the hair to return (fingers crossed).  If I let it grow, I look exactly like this guy from the toilet paper commercial.
•  My only other obvious sign of therapy has been my right eye.  The tumor there has ceased to cause blind spots but still limits my near vision significantly.  My left eye can read fine.  As the degree of this is still fluctuating I am hesitant to order another pair of soon-to-be useless glasses and have opted for store-bought reading glasses.  My recent solution is to buy a strong prescription strength pair and pop out the left lens.  It gives me an intellectual homeless look and helps keep the seat next to me empty on airplanes.
•  I have been shuttling between Ft. Lauderdale and Houston on Southwest Airlines, which has a couple direct flights a day and no change fees (important when you have those open-ended doctor appointments).  Last week I was elevated to their “A-list” category because of my frequent flying.  I now have the highest status on the cheapest, no-frills airline in the country.  Yeah!  Not exactly like George Clooney’s character in “Up in the Air”, but two bags of peanuts are always better than one.
•  Food tastes have largely bounced back from chemotherapy.  Before treatment I classified food into three categories – unacceptable, acceptable and enjoyable.  The split was roughly 15/60/25% and after treatment it was 15%/84%/1%.  My love of everything coffee related took a real hit, as I could not stomach it in any version.  This was especially painful after my significant purchase earlier this year of a gleaming chrome and black Swiss designed, Italian espresso machine.   I can now drink coffees and lungos and lattes, but the love has yet to return.  However, not having to wake up for anything seems to counterbalance this somewhat.  Ann and I have recently started eating raw vegan from previously eating a vegetarian diet.  This makes the food split about 98%/1%/1%.
•  Appetite is one of the common casualties of chemotherapy, which leads to inevitable weight loss.  This is so cruel as it is one point in your life that you want and need to gain weight but when you have lost any taste for food.  Note that cancer research has shown that the chemical marinol is one of the most effective anti-nausea appetite-building drugs available.  It occurs naturally in cannabis sativa (marijuana).  Just saying.
•  Those of you who know me know that only alcohol can beat out coffee in terms of most likely to be in my hand at any given time.  This went out the window during the first treatment, partially from recommendations of the medical team but mostly from taste.  Now I can stomach a hoppy wheat beer with a meal but no wine or other alcohol.  Besides the obvious physiological improvements that resulted I estimate this has saved me between $50 and $350 a week.  Who said cancer treatment does not have a positive side?
•  Other positives include the skin rejuvenation I received on my last round of chemotherapy.  My face peeled non-stop for almost three weeks.  As a result, I still have people telling me how much younger I look.   Laser skin resurfacing costs an average of $2,100 according to Dr. Oz.  In addition to significant costs savings from dry cleaning, hair products, commuting costs of gas and tolls, I think I may be in for a financial windfall.
•  Among the things I’ve been spending my new found wealth on are my own version of the LiveStrong yellow wristbands.  Yes, I sport the LiveStrong band and will get a LiveStrong tattoo once I kick this thing.  It is one of the most effective organizations to support patients and raise cancer awareness.  While I do not want to try to improve on perfection, the LiveStrong band is just a little polite for my own version of a campaign against the disease.  I wanted something that captures the magnitude of struggle and deep emotional connection that I feel to it.  So I have created my own wristband that me and my friends are sporting that is a little more on point.  Let me know if you want one.  Get one for grandma, too, but please note that they do not come in kid sizes.
My wife has used some of the money to pamper me in my time of need.  She does, however, get the least usable present award for buying me a gift certificate for a scalp massage after receiving a particularly fabulous one at a local spa.  A few days later we found out I had a skull lesion, basically a hole in my head that is probably best not massaged.  Awkward.  But this did not stop her from the requisite “hole in the head” comments.
Ann, of course, has been my champion through all of this.  We laugh, we cry – but mostly we laugh.  That’s why I love her and why I married her.  We know that many cancer books recommend latching onto a poem or a song that can help pull you through the tough times.  We could not get past a rewording of John Denver’s “Sunshine” where “sunshine on my shoulders makes me happy” becomes “sunshine on my shoulders gives me cancer”  (my first and second incidents of melanoma were on my left shoulder).  OK, you probably had to be there for that.
Another inside joke between us stemmed from the award winning biggest understatement of a nurse who, upon checking off my list of symptoms, stated that I was in “perfect health – well, except for the cancer.”  Now Ann I use this as our standard line when we so often have to go through these checklists.  We tell them “no nausea, no pain, no falling or injuries, etc., etc., – I’m in perfect health”, then - in unison - “except for the cancer!” [buh-bump].  Cracks me up everytime, but many nurses seem have no sense of humor.  I don’t think cancer has a sense of humor either.

Saturday, July 23, 2011


Good news on the TIL clinical trial, my insurance company has come on board to pay their share of the costs.  It took a lot of phone calls and explanations about the trial but they ponied up for a sizable portion of the very sizable costs (the sponsoring drug company pays much of the rest).  If I bothered to see if Cigna or Novartis had a Facebook page I'd ask you to friend them.  So with that out of the way I anticipated a rapid entry to the study but I found out this week about a potentially devastating delay, one that quite literally would be decided by a roll of the dice.  This clinical trial has two arms, one is standard TIL and the other is standard TIL plus an experimental vaccine.  Patients are randomized into each arm equally, giving patients a 50% chance to get in one arm or the other.  This helps the researchers determine statistically if one arm has different results than the other, a standard part of any trial.  The past few patients for this trial have been randomized into the vaccine arm which carries with it a few extra weeks of delay to prepare the extra vaccine.  Given that they can process only two patients a month in the trial, the vaccine delay and the length of the TIL procedure, that means a new entrant into the vaccine arm would be lucky to start the trial in September or October.  If that happened to me then it would mean being in treatment when my medical leave of absence from work runs out.  That means the end of my job.  That means the end of my benefits.  Good feeling rapidly gone.  So today I went to MD Anderson to roll the dice.  Its actually done on a computer, but I think they should make some kind of fancy lit-up roulette wheel since they dragged me all the way to Texas to do this.  But the roll came up in my favor, the non-vaccine study.  Dr. Patel is trying to start me in the study in the first week of August.  That may be delayed slightly, but unlikely long enough to complicate my work plans.  Sometimes things just work out.
     I recently started reading Evan Handler's "It's Only Temporary", an honest and often hilarious tale of leukemia survival (yes, you read that correctly).  Evan writes about facing down 50% odds of survival and how the gravity of that impacted him and the lives of his friends and family.  It put my view of being overjoyed about the TIL study, that may give me a 50% chance of response, in contrast.  I'm ten months into the median 12 months survival for melanoma patients, facing down an 85% chance of not seeing the 2015 Tour de France (and George Hincapie's 20th participation).  Unlike Evan Handler, I don't have a statistically significant chance of dying - I have a statistically insignificant chance of living.
     I've actually been digging into all these statistics recently.  In part because of my involvement in Florida's first LiveStrong event on October first and second.  z-Motion, the riding club I belong to and strong community supporter, is a primary sponsor of the event.  It will include rides and runs and walks to raise money for the Livestrong foundation and increase awareness of cancer.  I hope to ride in the event which occurs on the date Lance Armstrong was diagnosed with cancer.  Since my doctors approved me riding a stationary bike a few weeks ago I have been training and increasing my workload every day.  Last week I rode a 100 miles, this week 66 miles so far at an average 220 watts.  I would be relatively happy with those numbers before I got sick.  Through z-Motion I'm trying to use the story of my diagnosis to help attract more attention and support for the event.  I will also be speaking at a z-Motion gathering in August if I'm out of treatment.  Outdoor athletes like z-Motion racers and riders are at higher risk of getting melanoma and also have a lower probability of early detection than the average populace.  Its counterintuitive that a healthy lifestyle can increase cancer risks, and that's my message - my hook.  When I tell people about melanoma I want to be accurate, so I researched the latest grim stats.  Incidence of melanoma is increasing at a faster rate than any of the seven most common cancers.  It is one of only three cancers with an increasing mortality rate in men.  Its the number one cancer for twenty-five to twenty-nine year olds.  Someone dies from melanoma in the US every 62 minutes.  It claims more life years than any other cancer because it the average age of its victims is fifteen to twenty years younger than all other cancers.  There is no cure.
     Sobering thoughts like these usually drive me into attack mode, make me want to kill someone or something.  Fight, fight, fight. Then fight some more.  Yes, I know that someone has to be in those small percentages, and that is where I will be.  Always have been, always will be.  But sometimes the gravity, the seriousness, of it all comes over me like a water balloon rolling on to a pebble.  We are, after all, not talking about a hand of poker or a bike race.  I caught myself staring at otherworldly clouds outside the airplane window and wondering "what if?"  I don't know what if's, but I do know that right now - 34,000 feet up in this aluminum tube - is as close to heaven as I ever want to get.  Right now I want to get my feet on the ground and my arms around my little girls.  I want to hold them really, really tight until I top up my suitcase of courage and can fight some more for them, because I know I'll fight much harder and longer for them than for myself.  Cancer does not have small beautiful children to fight for.  Cancer does not have decades of birthday parties to attend, prom photos to take, wedding aisles to walk daughters down.  I do.  In spades.  And that's why I'm going to beat the odds.  You can bet on it.

Friday, July 15, 2011

The Experts are Wrong (Sometimes)

“It's another fact of cancer that the more informed and empowered patient has a better chance of long-term survival.”     Lance Armstrong

I’m by no means an expert in cancer diagnosis, but I’ve learned a few things from the experts and the so-called experts in the past year that have helped me avoid costly, perhaps life threatening mistakes. I feel that it is important to share these, because the most important lessons – as they often are in life – are the ones they do not put in books or brochures outside the doctor’s office.  So sit back and join me on a journey through my diagnosis experience and see the lessons I have learned.  They can literally save your life.

Experts have a hard time seeing beyond the focus of their expertise.
Many of the lessons I’ve learned deal with the fact that I am not, in medical terms, an “expert” and those that are considered experts are not always the right experts.  This can sometimes be because of the question that you - the patient – are asking, either implicitly or explicitly.  When I was starting to have mysterious black eyes on my right side I went immediately to an optometrist and then to an ophthalmologist.  I was already assuming, implicitly by my selection of specialist, that something was wrong with my eye.  These experts correctly told me that there was nothing wrong with my eye.  They incorrectly told me that everything was probably OK, that my symptoms were some temporary isolated trauma that would go away soon. I took only their expert opinion about my eye and disregarded their other conclusion, as I knew it was an assumption beyond their expertise.  The black eyes continued so I was right to disregard their sweeping statements of my good health.

Generalists can have a hard time looking beyond the obvious.
Assuming that my actual eye was OK I then went to my generalist doctor to see if there was something else that would explain the black eyes.  He agreed with the specialist that it was some kind of local trauma and that the big picture – my excellent overall health – led him to believe that there was nothing wrong with me.  He went further to posit a theory that I was punching myself in my sleep or sleeping on a closed hand that caused the trauma.  Perhaps my wife was beating me after I passed out from drinking too much?  He even offered a personal story from his boyhood as evidence of this possibility.  I asked specifically if there was something inside my head that could cause the black eyes.  I asked if I needed some kind of brain scan.  He vehemently claimed that it was impossible for something in the head to cause bleeding on the face – the head was just not made this way.  His assumptions and conclusions were all wrong.

If you do not like the answers you are getting, then examine the questions you are asking.
Still looking for answers I figured I needed a different kind of expert, one on the area around the eye and not one that just looked at the condition of the eye itself.  I had no idea what kind of expert that would be and asked my kid’s optometrist.  He recommended an ophthalmological surgeon who would have the expertise of the whole eye structure - the orbit – that contains the eyeball as well as optic nerves, etc.  I stumbled across a brilliant doctor in Boca Raton by looking for the eye doctor office with the most number of doctors and ad space in the phone book.  Most of these do cosmetic surgery, but they would have the right frame of reference I was looking for.  Immediately in my first meeting with him he assumed there was something behind my eye and ordered an MRI that plainly showed the growing tumor there.  I think he was brilliant because even though he could not immediately come up with a reason that an orbit tumor could cause the black eye, he went with what his analysis was telling him.  He was surprisingly honest and open with me about this.  He did later came up with a theory that the tumor was rubbing the walls of the orbit , rupturing small blood vessels that leaked blood into my face under the right eye causing the black eyes.  Brilliant.

Even world-class experts have a hard time seeing beyond the focus of their expertise.
I was referred to the best orbit surgeon in the US to deal with the tumor.  He treated me for what he assumed was a cavernous hemangioma (basically a knotting of blood vessels) in my right orbit.  He planned surgery after waiting two months for the blood to clear up in the orbit.  He never once brought up the idea that it was something else, a cancer tumor perhaps, even though his staff had my previous melanoma history.  I believe the disconnect of giving my history to his staff and then only listening to his opinion in the few minutes allotted to me allowed this mistake to happen and is a potential downside of large teaching hospitals.  I should have asked this question but I did not.  I should have insisted on a biopsy and I should have sought a second opinion, but I did not.  When I developed a skull lesion he continued with his treatment protocol.  Even when, the Friday before my scheduled Tuesday eye surgery, a PET scan showed I had metastatic melanoma throughout my body, he still believed the evidence suggested it was a hemangioma and not a cancer metastasis.  Was he covering his ass or just being stubborn?  I learned from this the medical theory of unified diagnosis, which says you look for the diagnosis that explains as much of the problem as possible.  The possibility that the eye tumor was a hemangioma while all my other tumors were metastasis was not unified.  But he was an eye surgeon focused on removing the thing in my orbit and he was not looking for the reason why it was there.  I made some mistakes here but thankfully it only cost me a couple months of diagnosis.  Lesson learned.

Finding the right type of doctor does not mean you’ve found the right doctor.
My first oncologist was very unpleasant, but I know that an asshole doctor can also be a brilliant doctor so I stuck with him through my initial staging process.  I found him after searching for the doctor at the regional cancer center that was most published, most involved in research and best known.  He was indeed the expert on melanoma at that cancer center and I was fortunate to get an appointment with him, or so I thought.  In his brusque manner he examined my PET scan and said I had to choose from one of four treatment options, with just a few sentences of explanation of each.  He urged me to make a decision quickly, and even called a couple of times over the next week asking what my decision was.  The options were all standard treatments with 0-15% response rates – chemo, high dose IL2, BRAF and Yervoy.  He did not mention any of the other options out there, and although he was familiar with the t-cell therapy he said I was not a candidate because my tumors were not large enough to harvest.  This was absolutely wrong, and the treatments he offered were standard and did not take anything into consideration about my specific health and condition.  Indeed, he did not ask anything about my current health or general medical history.  And when I told him I wanted an opinion from MD Anderson he said his cancer center could offer anything MD Anderson could.  Wrong, wrong, wrong.  I walked out of his office and never went back.  Another doctor I know, when told about this, asked me what you call the person that graduated last in their class at medical school?  “Doctor.”

Experts can be right and wrong at the same time.
My third opinion came from a well-known oncologist in Florida who was one of the nicest doctors I’ve met in my journey so far.  He was very generous with his time and was very willing to argue the merits of different treatment protocols, but I believe he was wrong in his conclusions.  Who am I to question a well-known oncology expert?  Case in point, he said that biochemo treatment was proven academically as ineffective and that he had personal experience with the failure of the treatment to cure his patients.  He asked me not to go through with it at MD Anderson.  This really perplexed me and I dove into the scientific data for answers.  I read many medical journals, often putting a “Dr.” in front of my name to get a trial subscription to the expensive ones.  What did I find?  After biochemo was first introduced and began making headlines it was rolled out across the country.  A study of the resultant experience with biochemo found that the earlier stated results of 30%+ response rates were not being replicated and the toxic side effects were much more difficult to patients than earlier studies had stated.  So the doctor was right?  No.  I also found a later study of this study’s results which showed that the treatment in the medical centers where there was biohemo expertise (Angeles, MD Anderson, etc. ) remained successful.  The conclusion was that the expert staff at these centers – doctors and nurses with special training and experience with the protocol - could better help patients handle the side effects of the toxic treatment which allowed the patients to get higher doses that lead to higher results.  Your local cancer treatment center could not achieve the higher doses as patients developed problems with the toxicity and therefore had the lower results.  There is still controversy about this – I believe stemming from some kind of institutional inferiority complex of many regional cancer centers - but it made sense to me.  It explained how he could be right and wrong and the same time.  Additionally, I made an estimation of the demographics of this doctor’s practice which lead me to assume that most of his patients were elderly as it seemed to treat the large retirement population where it was located.  He probably rarely had the healthy patient like me looking for rigorous treatment.  His cancer treatment experience and expertise did not match my needs.  He was right, but not right for me.
     I’m not saying that I am not still making mistakes, but I always question assumptions – others and mine.  The experience of cancer diagnosis is a scary one, more so than the actual treatment protocols.  I've heard it described as being transported to another country.  One day you are making coffee before work, taking your kids to school and planning your weekend.  The next day after diagnosis you are alone in a foreign land where everybody speaks a different language.  There are many people willing to help you, offering to show you the way home.  But the path home is painted in the art of self reliance.  That is the current state of cancer care, like it or not.
     Cancer is not going to get an easy break from a misinformed doctor.  Not with me. Not now. Not ever.

Monday, July 11, 2011

The Big Guns and the God of Thunder

OK, so it is time to bring out the big guns for this fight with cancer.  I mentioned the TIL clinical trial before and I've gotten a lot of questions about it.  On the right side and down a bit are permanent links to the study details and a great article about the process and Dr. Steven Rosenberg at the National Cancer Institute that developed it.  Dr. Hwu at MD Anderson used to be at NCI and brought the study with him to Texas.  The article in particular does the research work more justice than I can do here, but I'll give it a college try.  The TIL study utilizes adoptive cell therapy (ACT) which is also call T-cell therapy.  The acronym TIL stands for tumor infiltrating lymphocytes, my personal favorite because it sounds like a covert special operations military unit led by Steven Seagal.  My understanding is that in every melanoma tumor lesion there are some immune cells trying to do the job.  They are in the tumor but obviously they are not doing a good enough job because the tumor is growing, and that if we could reinforce these t-cells the body can successfully beat back the cancer.  The process developed at NCI involves removing some tumors and extracting these t-cells from within them and then growing the t-cells in vitro in a lab.  Then, to prepare the body for the new t-cells, they wipe out the body's entire immune system (lympho depletion) and replace it with the new t-cells.  The result is a cancer patient with a new immune system specifically trained to fight melanoma, and that immune system will fight that cancer for the rest of its life.  The durable results are over 50%, which is amazing compared to the other standard treatments that have a 5-15% response rate.  Many researchers believe this is the future of fighting cancer, even a potential cure, but up to now very few people have undergone the treatment (about 95 at NCI, 45 at MD Anderson and some others at a research center in Israel).  The reason so few have undergone the treatment, and that the clinical trial has not moved on from Stage 2, is that the patient needs to have an accessible tumor, t-cells that will grow in the lab and be strong enough to handle the tough treatment.  The list of health factors required to be considered for the study is 23 items long with 8 exclusionary criteria.  These criteria eliminate four of five potential candidates.  Fortunately for me, I meet all of those.  The treatment is also terribly expensive and is currently being undertaken at only the three research centers mentioned.
     My treatment at MD Anderson will start with seven days of lympho depletion with chemo therapy (fludarabine and cytoxan).  I'll be in sort of an isolation setting, we don't want anyone sneezing on me at this stage.  The lympho depletion is is supposed to be easier than the biochemo protocol I already underwent and Dr. Patel is even working on getting a stationary bike into my treatment room for that phase (her estimation of my constitution is refreshing).  Then, they'll grow the t-cells from the existing frozen millions into the billions in a special laboratory in Houston.  On Day 0 they reintroduce the cells into my body.  Then up to a week of consecutive high-dose interleukin (IL2) treatments, a biologic drug that will kick-start my new immune system into high gear and help my body to start utilizing the t-cells.  This has similar side effects as biochemo and is no picnic.  Low dose IL2 was a not to pleasant part of the cocktail in the biochemo I've already gone through so I'm sure high dose IL2 is even more fun.  They want to give me as many high dose IL2 treatments as I can stand (specifically what my liver and heart can stand) up to 15 doses,  most patients get 5-10 doses.  I told the docs to give me 15 even if I am unconscious to which they smiled as if to a child asking to go to the moon, but I think a little bravado - however unwarranted - goes a long way in reinforcing my commitment to this treatment.  I'll spend a few days to a week recovering in the hospital and then I'll go home for a couple weeks.  Then I go back to Texas and we do the high dose IL2 treatment a second time.  And then we wait, because the new immune system will take time to seek out and destroy the cancer.  The next scans will be in six and twelve weeks after the "birth" of my new immune system where we’ll see if there is any progress.  It may take many months before we start seeing results.  It is interesting that my new immune system will be the same as a newborn's and I'll lose all my existing immunities that I've worked so hard to develop.  That means next year I'll need measles, mumps and chicken pox inoculations.  It will be interesting to be sitting in the pediatric office waiting room next year with a bunch of toddlers.
     I believe cycling, and very often professional bike racing, to be an accurate metaphor for so many things that happen in life.  In Stage 3 of this year's Tour de France Tyler Farrar, the best sprinter America has ever produced, looked like a possible to win the stage.  It was also July 4th and for an American on an American team to win the stage that day would be a phenomenal achievement.  However, the odds were long and Tyler faced many stronger and faster foes also fighting for the stage.  The racing had been touchy and a tour-ending, or even career-ending, crash was a definite possibility.  On Tyler's team is Thor Hushvold, the Norwegian "god of thunder" who was wearing the yellow jersey as the overall race leader in the Tour de France.  Thor also wears the rainbow jersey signifying that he is the current reigning world champion road racer.  Coming in together to the hectic last half kilometer of the stage, Thor jumped through a blind corner towing Tyler to the front of the nervous pack.  I've never seen a yellow jersey lead out a sprinter at a Tour de France but Thor is like that, a team player confident of his world-best skills and always willing to jump after any potential victory.  After Thor gave it his all he pulled over and let Tyler go on to sprint the final meters against his foes to win the biggest stage victory of his life.  You can see Thor smiling in this picture, resplendent in his yellow jersey, a few riders back from Tyler.  In many ways MD Anderson, and Dr. Patel, is my yellow jersey teammate leading me into the final section of the most important race of my life.  They are world champions in fighting cancer and they go aggressively after any possibility of victory.  And I know that they can get me close - closer than anyone else - but it is critical to remember that victory will require me to sprint the final meters alone and I know this will take everything I have.  But I also know that cancer will not beat me to the line, cannot beat me to the line,  when I have a world champion leading me into the finish.

Saturday, July 2, 2011

Scan Results

Well, we got the results yesterday of Thursdays CT and MRIs and we got neither a winning lottery ticket nor devastating news - something more in the middle and along the lines of our original treatment plan.  The biochemo did not shrink my existing tumors but they also did not grow.  The tumor in my hip looks stable enough that Dr. Patel approved a stationary bike for me, which is pretty exciting.  Unfortunately, we did find two new tumors near my kidney.  Sometimes they call biochemo a "springboard treatment" specifically because it halts the progress of your existing cancer while you have to wait for other treatment options.  For us, we've waited five weeks for our other treatment option – the TIL study - and the t-cells they extracted from me in May have grown successfully into the millions.  This means that I can likely enter the TIL clinical trial at the end of July.  More details on what's involved in that later.
     So, what does this news mean?  Its some cold comfort that this was the plan from day one.  The TIL study was my number one goal and the reason we went to MD Anderson, but we did not get the sudden success from the biochemo that we held as an outside hope.  Our recent optimism was born of my surprisingly strong recovery from the biochemo.  We were made to expect to limp through the time in between treatments, to expect blood transfusions and emergency room visits, but my recovery was rapid and complete.  Now, two weeks after my second round - which was supposed to be the worst - I feel the best I have since entering treatment.  I even hit the hotel gym before seeing Dr. Patel yesterday.  I do not think my stamina was working in the same direction as the biochemo treatment.  Chemo works by destroying you - hoping that the healthy part of you is destroyed a little less than the cancer part of you.  The TIL treatment, however, relies on your body’s ability to fight, to recover and to attack that which attacks it.  This treatment seems to play into my strengths.
    Switching to the TIL treatment has many other positives.  In addition to having a complete attack plan, it means that I'll be spending a wonderful bonus time at home with the family while I'm feeling good.  It also means I may return to work after recovering from the second IL2 treatment and that I can resume a relatively normal life until otherwise notified.  This is all good news but delivered with a bit of a setback.  Lance said that cancer taught him to be comfortable with ambiguity, now I know what he's talking about.
     So this week we're going to take the kids to Disney World and enjoy the downtime before the big attack in a couple of weeks.  I'll continue regaining my stamina and getting stronger and healthier each and every day.  Meanwhile, cancer can sit there and wait, nervously anticipating the billions of specially trained tumor infiltrating lymphocytes that are coming its way soon.  Think about how many zeros are in a billion, cancer, and I'll be enjoying the Magic Kingdom.