Stable

Last week's scans show mostly stable disease, especially a reduction of tumor growth in my liver. The radiologist's report on the brain MRI seems inconclusive. Dr G may change my treatment simply because the Abraxane is becoming more toxic and lowering my counts too far. More news next week....

Stability!

Dr G and the radiologist who read my recent CT scan agree that the scan shows stable disease. Of course, that means we don't know why one of my tumor markers increased. But stable is always good.

I start Avastin again next Monday. This drug, which I took for about a year while on Abraxane the second time, acts like a booster for the other cancer therapies. Although the FDA recently decided it was not effective enough for treatment of metastatic breast cancer, some people, including me, respond very well to it. I'll get the Avastin every other week by infusion. It should take 90 minutes to two hours for the whole thing, from the time they access my port to the time they de-access me. I will continue on the Afinitor+Aromasin+high dose Faslodex combo.

More than 30% of patients taking Avastin have these side effects:

Generalized Weakness
Pain
Abdominal pain
Nausea & vomiting
Poor appetite
Constipation
Upper respiratory infection
Low white blood cell count. (This can put you at increased risk for infection.)
Proteinuria (see kidney problems)
Nose bleed (see bleeding problems)
Diarrhea
Hair loss
Mouth sores
Headache

It's hard for me to tell what side effects I had the last time I took Avastin because I received it with chemotherapy. So, say it with me:

This drug combo should be highly effective with minimal side effects.

CT scan

Yesterday I had a CT scan to determine the current state of my cancer. Normally these go easily, but this time I tried really hard to brink both bottles of the barium solution. I got through one and almost all of the second bottle. The barium didn't sit too well in my tummy, and by the time I got home it had caused some unpleasant diarrhea which lasted most of the evening. Yuck!

I get the results from Dr G tomorrow afternoon.

Stable!

I received a copy of the radiologist's revised report on my recent CT scan. When compared to the more recent scan in April 2012, things appeared stable today. And stable is good!

No word yet

I am still waiting to hear from Dr G's office about the radiologist's review of my recent CT scan. Evidently the radiologist wanted to compare this one to the April scan, so they had to request that record from SCCA. Today is a national holiday. I will call on Thursday to get the latest.

Scan results - I think

I think the news is good but won't be certain until tomorrow. When I saw Dr G this morning, he had prepared to tell me that the scan results were bad -- but then we realized that the radiologist reading the scan had compared it to one from August 2011, not May 2012. Dr G was unhappy; he's had this experience before. His staff called radiology and the scan should be re-read tomorrow. Then Dr G pulled up the images and he did a comparison to the May images. In his opinion, things look good, but he still wants a radiologist's opinion.

The other good news is that my both tumor markers have decreased by 10 points. However, in the case of the CEA, the percentage of decrease is much larger than that of the CA 27.29. So I will continue on the Afinitor combo. I also had my monthly double shot of Faslodex today.

I kvetched a little to Dr G about the neuropathy in my feet, and he remembered a report from the recent ASCO conference about how the drug Cymbalta (duloxetine) reduces peripheral neuropathy pain. Dr G wrote a prescription which I expect to pick up later today. This drug quite expensive, so we may be in for a conversation with the health insurance company again.

Scans

Tomorrow I will have a CT scan to determine what's happening with my bone and liver mets. Dr G doesn't like to order too many scans for me -- lots of radiation isn't good, especially if one has lived as long as I have with advanced cancer -- but scans give good information on the cancer's progression. It's been a month since I last saw Dr G, so a scan and labs are in order. I will see him on Thursday and get the results then.

So what have I been up to? I have been feeling very well lately, hence my lack of posting. I am too busy just living my life! In the past week I:

• attended a meeting of my support group of young women with metastatic breast cancer
• found out that yet another young woman I know has been diagnosed with mets
• went to a synagogue committee meeting
• took the rabbi out to lunch at Cafe Flora 
• participated in a telephone marketing survey for a cancer drug
• went to my regular support group
• attended a high school graduation party for a friend's child (and baked quadruple-chocolate cookies, made with melted dark chocolate, chocolate chips, cocoa and chocolate nibs)
• slept through my yoga class (sorry!)
• led the Torah service on Shabbat and since I was the only Cohen present at the time, also had an aliyah
• hosted lunch for some friends from my days dancing in Radost
• celebrated the wedding anniversary of some good friends
• and took the Theo Chocolate factory tour again and ate too much chocolate today!

As you can see, life has been filled with good times. I aim to keep it that way.

Good news and good news

Stable is always good news, so when Dr G told me yesterday that all my mets appeared stable, I was very pleased. "Gratifying" was the word he used. Then I read the report more carefully. The prior scan had indicated a new lung metastasis. The current scan? No lung met in sight, and the radiologist had access to the old report and images and knew where to look for things. So, good news!

Although my tumor markers had risen, Dr G also explained that it can take time for tumor markers to fall when starting a new therapy.

Then we looked at the brain scan and -- no brain mets! Can I say that any louder? NO BRAIN METS! This is when Dr G asked me if I had told Seattle Radiologists where I'd gotten my last scan. Yes I did, and they told me before I left the office that they'd already requested the images and report.

It seems clear that this combo (Afinitor+Aromasin+high dose Faslodex) is working well and has been very tolerable so far. I've had some side effects, but they haven't lasted long. Even the remaining mouth sore isn't too troublesome and hasn't interfered with my eating.

Good news indeed!

PET scan

I had a PET scan today to determine the effectiveness of the 30 days I have been on the  Afinitor+Aromasin+Faslodex combo. It meant getting up too early, not having breakfast, and not even being allowed to listen to music after drinking the barium solution and getting the radioactive dye. This last was because I also had a PET brain scan, and they wanted no interference with that, even from listening to music. Instead I took a 45 minute nap, followed by another nap while on the scanner bed.

Then I went off to Cafe Presse for my favorite post-fasting breakfast: omelette with sautéed mushrooms, salty and crunchy frites, and a cup of hot chocolat chaud served with freshly shipped cream. Plus lots of water, to flush the radioactivity out of my body. It's just about the best meal I know.

I get the results of this scan next Thursday when I see Dr G, and at that time we will either stay with the current combo or determine a new course of treatment. In the meanwhile, I have lots of singing and dancing to look forward to at Folklife, plus a visit from my mother. (That will likely include some shopping as well. What could be better?)

Bad news

Yesterday I saw Dr G and got the results of Tuesday's brain MRI and labs. The MRI suggested progression in the central nervous system, meaning I have new, and growing, brain mets. My labs were significantly higher than eight weeks ago, with tumor marker CA 27.29 at 214 and CEA at 40. (Both had been at or near normal.) Clearly this clinical trial is inadequate to treat my cancer.

Dr G and I discussed several chemotherapy drugs that cross the blood-brain barrier or which have a track record for treatment of brain metastases. We also discussed further radiation therapy. Gamma knife may be an option again. Whole brain radiation (WBR) is not an option, as it might likely cause dementia. (My radiation oncologist agrees.)

Although I took the final FDG PET scan of the trial on Monday, no results were available in my electronic record at SCCA. Having any more information might have helped in yesterday's difficult conversation with Dr G. It looks like I will have to wait until after the FES PET scan next week to get information from Dr Gadi. Then I'll see Dr G again to make a plan.

This news was like receiving punch in the stomach. Last year, my complaints of "feeling stupid" led to Dr G ordering a brain MRI. This time I have no symptoms. Indeed, I feel great on the trial regimen. But it's so not working.

I hate the waiting game, when I don't have all the information, just enough to scare the daylights out of me. I was a little taken aback when Dr G asked me directly what Iw anted to do. I think this was "doctor-speak" for was I ready to stop all treatment.

I'm not ready to stop treatment yet, but neither am I interested in treatment which will impair my quality of life drastically. (Hence no WBR, or chemo which would increase my neuropathy.)

Dr G made an analogy to the Battle of the Bulge, which was the last major Nazi offensive against the Allies in World War Two. I could now be facing my last effort to pound my cancer down into submission. 

I hate these battle images, but I did have a talk with my cancer last night. I told my cancer that if it gained so much ground, it would lose the ultimate battle. If it kills me, then it dies too. 

Years ago, not long after my mets diagnosis, I told my cancer that as long as it behaved, it could have a place in my body. The moment it acted up, I would hit it with everything at my disposal. Well, my cancer has been more or less quiet for almost a decade. I am prepared to hit it hard now, but still give it living space, if it will make the deal.

Scans, scans, scans

This week I am in the third and final round of scans for the clinical trial at SCCA.

Yesterday I had to FDG PET scan, the one done fasting. Rik is off school this week, and he took me to SCCA at just past the crack of dawn. I hadn't slept well, so relaxing in the chair while waiting for the radioactive dye to uptake was no problem. I am sure I slept because I woke myself with snores on several occasions. Same with the scan itself.

Afterwards we tried a new place for blunch. (Blunch is what Rik's mother calls the meal between breakfast and lunch. Brunch is more of a late breakfast.) We went to Brave Horse Tavern, where our server was a former student of Rik's. Now, of course, instead of being a short 8th grader, he was a tall young man sporting a mustache. I dined on hearth roasted asparagus with melty teleme cheese, grated egg, and green garlic bread crumbs and shared some good fries with Rik, who had a burger.

By the time we got hime I was ready to crash, and we both napped for more than an hour before attending a volunteer training for theatre ushers.

Today I have a brain MRI as part of the follow up to the brain metastases discovered last spring. This is at Dr G's office, where they will also draw blood to test my tumor markers.

On Thursday I see Dr G, who will give me the results of the brain MRI, the labs, and hopefully the FDG PET scan (assuming SCCA gets him the report in time. I asked for them to fax it but you never know...).

In the middle of all this I'm also going to the dentist for a regular check up. It's a week of doctors, even more so than usual.

The final FES PET scan is next Monday, and I see Dr Gadi next Wednesday for the final, final report on if I am eligible to continue with the trial protocol.

End of vorinistat round 1

I thought I was supposed to take my last dose of Vorinostat tonight, but have been asked to continue for one more day. I won't be sad to stop the vorinistat. It's been tolerable, although I have had both constipation and diarrhea, as well as some nausea and fatigue. But as I said originally, I think I can manage almost anything for two weeks.

Tomorrow I begin the second round of PET scans and I think that has something to do with continuing vorinistat for one more day. I have the FES PET scan on Monday and the FDG PET scan on Tuesday.

REFRESHER: The FGD PET scan is done while I am fasting, to measure the uptake of glucose to - presumably - malignant tumors and metastases. The FES PET scan measures the uptake of estrogen to the malignant cells. I'm taking the vorinistat to re-sensitize my cancer to estrogen. On Tuesday I will start taking Femara, an aromatase inhibitor, for six weeks. It's job is to begin reducing the number and size of metastases.

I took Femara at the very beginning of my life with metastases in 2002 and I think it worked for about two and a half years. When I saw Dr Gadi last week, he told me he wanted to use either Aromasin or Arimidex for the next trial step of aromatase inhibitor. I asked if it made any difference that I'd been on Femara the longest, and he consulted with the clinical trial coordinator. Lo and behold, I will start Femara.

Femara worked for a long time, and was very tolerable. Let's hope it will do so again!

Trial update

On Monday I took the first dose of vorinistat, one of the two drugs that are part of the clinical trial. So far I think I have seen no ill effects, although I did have a nose bleed last night and again this morning. Bleeding from the nose or mouth could be a sign of low platelets, so if it continues to happen I will call the doctor's office to report it.

I also spoke with the radiologist in charge of the scan part of the trial. I had asked him to review the two scans taken at UW and SCCA and compare them to my previous PET scan from last November, taken at Minor and James. He said the scans may or may not show changes in my liver mets, due to having been taken by separate machines and read by different radiologists. And of course my tumor markers have continued to drop to almost in the normal range.

This trial expects to show that cancers which were originally estrogen positive, and then changed over the course of time to no longer be as estrogen positive, can be returned to their original sensitivity. The vorinistat, followed by an aromatase inhibitor, would presumably make this happen. Evidently I am exactly the kind of patient the SCCA docs were looking to enroll in the trial. My cancer was originally highly ER+/PR+ and has changed over these nine-plus years to be less so.

The scan part of the trial  measures the success of the drug combination. A regular FDG PET scan shows areas of cancer by their sensitivity to glucose. Tumors uptake glucose more quickly than other cells. Hence I fast before the scan, to have the least amount of glucose in my system. The FES PET scan measures the uptake of estrogen to tumors. No fasting needed!

This first set of scans acted as a baseline. If the drug combo works, the researchers expect to see some change in the tumors' uptake of estrogen, and perhaps a reduction in the size or number of tumors as well. So I will have another set of scans after taking the vorinistat for 14 days, and a third set of scans after taking the aromatase inhibitor for six weeks.

This is a lot of information to take in. Feel free to re-read my explanation. This is the best I understand the whole process.

The second opinion

Last week I met with Dr V K Gadi of Seattle Cancer Care Alliance (SCCA) for a second opinion on next choices. Here's what he had to say:

My cancer is "indolent," that is, slow-growing. It's taken 13 years to get to this point from my original diagnosis in 1999. That also means it can be harder to treat with chemotherapy since these meds attack faster-growing cells. And I get the side effects even if the chemos aren't as effective on my slower-growing cancer.

My treatment began with aromatase inhibitors (AI's) and other estrogen fighting drugs, lasting for seven years. High dose estrogen and use of two AI's such as Faslodex and Aromasin are possible treatments.
Side effects from chemotherapies present more of an issue than the chemos themselves. Xeloda may still be a possibility, even though Dr G has been reluctant to prescribe it, given my hospitalization in 2009 when taking 5FU. (Xeloda is the oral form of 5FU.)

Targeted/biological agents, such as Avastin could be (and have been, in the case of Avastin) included in my treatment plan.

We should retest my DNA to see if I carry the BRCA1 and/or BRCA2 genes. Whole genome testing might not have been available in 2003 when I had this done and things have changed in the interim years.

There is a clinical trial I am eligible for, of Vorinostat with an AI and imaging. This trial tests both the efficacy of Vorinostat for metastatic breast cancer (the FDA has already approved it to treat other cancers) and the efficacy of a fluoroestradiol scan (FES). As I understand it, the FES is similar to a PET scan but without the glucose solution.

I'll outline the trial in my next post. But first I have to vent a bit about SCCA itself, since the trial would require my receiving care there for at least eight weeks. Bearing in mind that I don't handle change well these days, here are my impressions of SCCA:

Of the four individuals I met, only one person, the teaching fellow, offered her name first in greeting me (as in, "Hello Ms Cohen, my name is _______.") The PA who took me to the office, Dr Gadi, and the research assistant for the clinical trial did not. The PA simply stood over me while I was in the waiting room. When I noticed a pair of legs in front of me and looked up from my book, she said, "Ms Cohen? I'll take you up to see Dr Gadi." I had to ask, "And your name is ....?" Dr Gadi bounced into the exam room talking about treatment options. I had to interrupt him to say, "You must be Dr Gadi." The research coordinator and I met in the hallway, and I was the first to ask, "Are you looking for me?" Not a good way to welcome a patient. 

While waiting to be seen, I couldn't log into the SCCA wifi network. This may seem petty, but if that's what helps make the wait seem faster, or if I need to be in touch with someone via email, not having access to wifi is extremely annoying. I spoke with a man who was working on his laptop, and he said he frequently could not log onto their system. 

SCCA is affiliated with the University of Washington, and so residents/teaching fellows (maybe this isn't the proper term?) participate in seeing patients, under the supervision of the treating physicians. I recalled from my previous visit a year or so ago that I would see a fellow before I saw the oncologist, so I was prepared for my appointment to take an additional hour.  

As I expected, the teaching fellow came in first. She reviewed my history and then was unable to locate the most important page in the box of medical records I hand-carried in the prior week: the chart Dr G made with all the chemos I'd taken, when I began and why I'd stopped taking them. I had carefully placed this paper on the top of the entire box of 250+ sheets so that the doctor would see it first. Neither she nor I could find it in the pile, and she had to ask the secretary to call Dr G's office to ask them to fax another copy. This inattention to detail frustrated me. 

Dr Gadi was so excited to find another patient who would qualify for the Vorinostat trial that he set up a meeting with the research coordinator for that same day. I spent another hour-plus waiting for the research coordinator and then talking with her. I am glad we spoke, because she was able to answer many of my questions. But I had not prepared to spend more than three hours at SCCA.

Something about SCCA just rubs me the wrong way. I'm sure the people are perfectly pleasant, but both my experiences left me stressed, annoyed, frustrated, and out of sorts. I was so pissed off and tired from the long day that I couldn't focus at rehearsal that night and inevitably, took out some of my frustrations on my friends in Dunava. So regardless of my eligibility to participate in cutting-edge science, regardless of how I might benefit from this new, experimental treatment, I have to ask myself if it will be worth this level of frustration. So much will depend on what Dr G thinks and if my health insurance company will fund the lab work and doctors' visits. But it will really come down to if I can stand going to SCCA.

Dr G says....

1. The brain MRI results were very good and the three lesions are faint.

2. The Abraxane has clearly become too toxic. Plus my CA 27.29 tumor marker is about the same as last time, so it's also no longer as effective. I get to take a two week break from treatment in hope that the side effects (fatigue and neuropathy) ease up.

3. Given the above, he wants me to seek a second opinion from an oncologist at Seattle Cancer Care Alliance. Dr G could think of six potential chemotherapies, and wants the benefit of other wisdom in deciding which one to use next. So I need to help gather all my volumes of medical records from Swedish Medical Center and from Minor and James, which have never been consolidated into one place.

4. I will see Dr G again in two weeks, at which time he wants to start me on something.

Then he showed me a web site with his principles of oncology, but I neglected to get the URL so I can share it with you. They were concise and focused -- just like Dr Goldberg.

Last Dr G gave me a hug, which tells me that he really cares about me as a person, not just as a patient.

Scan results

The results of Monday's PET scan were good -- the liver mets are shrinking and there appear to be no new mets to report. My tumor marker came down from 89.9 at the end of August to 73 today. This is a slower rate of decrease than in the past few months but still a decrease.

Dr G says I should continue on the Abraxane/Avastin. When I reported the change in neuropathy from pain to numbness, and my fears regarding a fall, he told me that it would be a mistake to stop now while the cancer is clearly responding to the treatment. If I stopped or he decreased the dose, it might turn cancer cells partially responsive to this treatment into resistant cells. So I will start another cycle of this chemo cocktail next Monday, then re-test my tumor marker in a month. I'll also phase out the gabapentin and start taking Lyrica for the neuropathy. Maybe this new drug will give me better protection from increasing neuropathy.

I'll also have a follow up brian MRI in the next weeks. I am supposed to get this test every three months since the gamma knife follow up in August. I think I'd like to time this scan so that I can get the results when I next see Dr G without having to wait a long time for them.

All in all, this is the kind of good news I like to hear!

Today's update

In preparation for today's PET/CT scan, I had to eat a special diet for the previous 24 hours. No carbohydrates at all; high fat and protein. That meant no milk in coffee; hardly any vegetables; no fruit at all.

For breakfast I made a two egg omelet, sauteed in butter, filled with sauteed mushrooms and some cheese and a cup of herbal tea. (Missed my morning mocha ALOT!) At lunch I polished off the rest of the leftover chicken from a couple of days ago. I snacked on a handful of almonds. At dinner, green salad, freshly picked from our garden, and broiled lamb chops. I drank a lot of water too. What did I miss? No bread, potatoes, CHOCOLATE. That last was the hardest to give up, even for a day.

Then I fasted for 12 hours before the scan. I managed to drink all of the glucose solution without too much gastro-intestinal trouble. After the scan, I met some friends for brunch where I devoured a buckwheat pancake topped with strawberries, blueberries, raspberries, and freshly whipped cream and a huge mug of coffee. After I cam home I immediately ate a piece of chocolate, thereby getting my daily dose of vitamin CH. I guess I'll have to have two pieces today to make up for missing yesterday.

I get the scan results from Dr G on Wednesday, as well as my latest tumor markers (hopefully at normal for the first time in a long time). We'll see what comes next.

My Avastin-related bloody nose has subsided a bit and I no longer have mucus running down my face if I can't get to a tissue in time. I am really looking forward to this week off treatment and hope to recover full strength soon.

Now I plan to get some nap time on the sofa, since my evening will no doubt be disturbed by several trick or treaters. We don't really celebrate Halloween. I moved the carved Bob O'Lantern to the front steps and will light a candle in it to encourage some kids to come to the door. Maybe I'll see some neighbors and former neighbors. Teens, stay away. Halloween is for the little kids.

Good news!

Monday's CT scan indicated that my liver mets are getting smaller, although there are still seven of them. On top of this, my CA 27.29 tumor marker has fallen yet again from that all-time high of 300, to 150 at the end of June, now at 85! Altogether this means that the Abraxane/Avastin combo is really working.

Dr G says that he wants to keep me on this chemo combo. When my CA 27.29 drops to normal (30), he will order a PET/CT scan to check on where in my body I have active mets. Then he'll order another couple of rounds of chemo before he gives me a "vacation."

Although this was truly good news, it still is hard to face more months of chemo. If my tumor marker continues to fall at this rate, I am predicting about two months of active treatment before a PET/CT scan will be possible. A round of this chemo combo is three weeks on and one week off. Then another couple of months of treatment after a scan. I feel challenged by spending that much more time bald, feeling poorly, with low energy, etc. But if it will kick my cancer into submission, then somehow I will find the inner strength to keep doing it. And all indicators appear to show that this treatment does indeed work for me.

As an aside, I told Dr G about feeling stuffy and having a runny nose for the past two weeks, plus a mouth sore that won't go away. He suspects either I have allergies (hah!) to explain the nose and sinuses, or that I have a viral infection. It's likely not chemo-related, since my white blood cell counts are not low and that's what usually causes mouth sores.

He bumped up my dose of valacyclovir from 500 mg daily to 1000 mg twice a day to wipe out any viral infection. He also recommended Allegra in case it is allergies, but I am reluctant to take that at the same time and have it mask the symptoms. Then I'll never know if I have allergies or a viral infection. (I may have had a viral infection in my mouth and throat last summer. Or it may have been a side effect of the Doxil. We'll never know, since I was treated for both.) Plus I am more anemic than usual, which explains my feeling tired all the time.

All this helped me understand why I felt so bad on our recent Alaska cruise. I really was sick, and no amount of hot water with honey and lemon, using the neti pot, or gargling with a salt water/baking soda solution could really help.

Dr G is giving me another week to recover from whatever is going on in my head and mouth. My next chemo is scheduled for September 12, presuming I feel better.

CT scan

Today's CT scan went as well as possible, I suppose. The nurse who accessed my port did a fine job, but when we got to the imaging area, I learned that I had the time of the scan wrong and was an hour early. Luckily they were able to squeeze me in but I still sat around for 40 minutes with nothing to do but read. I could have slept later than 7 AM after all.

Then I had to drink the incredibly yucky barium stuff that gives me diarrhea, makes my stomach ache and makes me feel nauseous. I got through the fist bottle and about half of the second bottle before I felt too nauseated to continue. Next I realized I hadn't dressed properly. I wore jeans with a metal zipper instead of yoga pants, and so had to put on a hospital gown for the scan. Plus I was wearing a hat with a metal wire in the brim and so had to wrap a towel turban to keep my head warm during the scan. I prefer to wear my own clothing (keeping at least some control over the process) and had changed my hat at the last minute before leaving the house. Oh well, what can you do?

After the scan I was hungry despite my bubbly tummy so took my mom to the Mediterranean Kitchen for some farmer's wings -- marinated for 24 hours then grilled and covered with garlic sauce and served over fluffy rice. We came home and I tried to nap but couldn't really fall asleep. Now the sun is shining but I still feel an upset stomach and so will try to sleep a bit.

Scan results and treatment update

Last week's ultrasound results were neither positive nor negative. I continue to have stable disease in my liver, meaning the Gemzar didn't really work all that well for me.

Dr G has decided to put me back on Abraxane. This is where I started chemo exactly a year ago. He did not order scans before I started the Abraxane. After nine or so treatments, I had a CT scan which found the liver mets. We don't really know when they appeared.

He switched me immediately to Doxil, which I did not tolerate. In the past year I have also taken Adriamycin, high dose Faslodex, Navelbine and Gemzar, all resulting in stable disease but no reduction in liver mets and continually increasing CA 27.29.

So, since I tolerated Abraxane well last year, I will start on it again next Monday. At least I know what to expect -- low blood counts, hair loss, nausea, fatigue and maybe peripheral neuropathy (although I don't remember this from last year).

Last year I had all my hair buzzed off just as it started to fall out, but I still had stubble all during the spring, summer and fall chemos. I was never baby-butt-bald. So I think I will try to live with hair loss this time instead of buzzing it all off again, and see if it does really all fall out, or if it only thins.

It does mean I will likely be hairless when we go out of town for a family celebration in June. I still have the wig I bought last year and many, many scarves. If I am bald, everyone can just deal with it. 

Dr G knows about our planned trip and hopes to see some results before we leave. I think that means I can look forward to another scan mid-June. As he told me today, "You're in good shape. We just have to find the right thing for you." We had a moment of emotional connection together and decided we are exactly the right doctor-patient team together.

(If you search through my blog for posts on Abraxane from 2010, you'll read that at the time I was dealing with a severely dislocated elbow, lymphedema, fear at starting chemo for the first time in eight years, and incipient depression. After having been on chemo for most of the last year, I can safely say that my fear is reduced, I know what to expect from Abraxane this time, my elbow has healed and I am no longer clinically depressed. But I think I will stay on the low dose of sertraline for the time being, just in case.)