Of Cats and Cancer

Recently I was listening to an online talk about meditation.  Thoughts are transient and without substance.  Think of a thought as a cloud in an otherwise blue sky.  Imagine it dissipating as it slowly drifts away.  Too bad my anxiety fueled obsessive thoughts don’t dissipate, but can remain lodged in my head for hours.

But it wasn’t a useless lesson.  My thoughts are like the cat meowing for his breakfast, insistent and annoying.  If you feed the cat in response, you’ll only encourage it to come back and be more insistent and more annoying the next time.  These thoughts are best ignored or noted for later consideration, but that doesn’t immediately stop them from being insistent and annoying.  I’ve developed an impressive ability to ignore the cat’s meowing, I can do the same for obsessive thoughts.

With my recent third cancer diagnosis, a painful stent in my urinary tract, a bump in my chest from the chemo port, and a case of chemo brain, my head has turned into crazy cat lady central.  I simply can’t count the number of obsessive thoughts meowing away.  Frankly, it’s enough to aggravate my allergies.

The most basic question I face in my life today is which cats do I want to feed?  Which ones do I want to encourage?  Here’s one that’s making a contended purring sound, he gets some kibble.

I’ve written previously about my dire diagnosis and atrocious prognosis.  It’s good to be mindful of it to the extent that it keeps me motivated to stick with the treatment plan and seek out anything that can help me limbo under the low line of the survival curve.  But beyond that, it’s not good dwell on it.  We’ll keep this cat in a crate in a corner of the basement.  That’s not animal cruelty, it’s just a metaphor.  No actual cats are being kept in crates in my basement.

The cat I’ve chosen to adopt, call my own, and allow to freely roam around the house is called Mizuno, the marathon cat.  He was written out of “Cats”, the musical, as his name was difficult to rhyme and sing.  Tough break.  But I digress.

I fully believe that my treatment will be effective and allow me to train for and run a marathon.  If anything, the biggest obstacle between me and my second marathon is overuse injuries to my joints, as that has scuttled several previous attempts.  Since my diagnosis I no longer have a time goal, just a desire to finish a marathon no matter how long it takes.  That will hopefully translate into less joint stress.  In fact, I plan to walk as much as run in this marathon.

It’s a Jedi mind trick I play on myself.  Cancer is not viewed as a deadly disease (though it still is), but treated as a mere obstacle to my marathon goal.  It’s a problem that must be solved.  The tumor in my bladder must be shrunken to the point where the stent can be removed, so that I can resume long runs without pain and blood in my urine.

Being able to envision a meaningful future is key to keeping my sanity.  It’s the difference between enduring cancer treatment, or simply suffering medical torture.  Laying around the house most of the day watching Netflix may sound like a lot of fun to some people, but it’s leaving me quite uninspired.

There are parallels between marathon training and chemotherapy.  Marathon training involves periodic long runs which are stressful to the body and cause it significant damage.  Following each long run it is necessary to rest and have shorter, easier runs while the body recovers from and adapts to the long run.

Chemotherapy is similar. Instead of a long run, the body is stressed by having poison injected into it which causes significant damage.  Following each infusion is a period of rest, gentle exercise, and recovery.  Where chemotherapy and marathon training diverge is that the body generally gets stronger and more fit during marathon training, while with chemotherapy the body is beat further and further down with each cycle.  Oncologists would make bad marathon coaches, as they would definitely overtrain their athletes.

Mizuno, the marathon cat is the cat I choose to feed.  May he live long and have many kittens, including PET, the complete remission kitten, Peaks, the hiking kitten, Splinter, the firewood cutting kitten, and Jobber, the return to work kitten.

Routine Update

Chemotherapy is going as well as can be expected.  While I still have pain, it’s now generally responsive to pain medication and hasn’t gone past the end of the pain scale since chemotherapy began.  As this cancer can’t be tracked through blood tests, there’s no way to tell if this is due to tumor shrinkage, or just my urinary tract settling down after having the stent inserted.  I’ll be scanned again at some point during chemotherapy, and that will show what the tumors are doing.  There will be a lot of scanxiety associated with that scan I’m sure.

Side effects are the usual suspects of nausea and digestive issues and pain, all manageable with pills.  There’s also fatigue, which is exaggerated by the previously mentioned pills, and can’t be helped but to get a bit of exercise and plenty of rest.

Last week, just hours after my most recent chemo infusion I was running around at the indoor track, though with lots of walking because of that annoying stent.  This wasn’t an act of superhero powers, but rather a combination of my fitness from before treatment began combined with dexamethasone keeping the chemo side effects at bay.  Let me put it this way: Cancer and its treatment have reduced me from running 10 miles to walking 2 miles and everybody is just amazed at how active I am, while I look at myself and see an 80% reduction in capability.

And of course, I wrote that paragraph prior to this week’s indoor track session, which turned out to be a bust.  I had overestimated my progress, and started off with too much running on not enough pain medication, and after a few laps had pain and an insatiable urge to pee, even though I just went a moment ago and my bladder was far from full.  So I’m in the bladder penalty box for now, when I recover in a day or so I’ll go back to walking which I’ve been doing recently with increasing success.

But hey, I’m still here, still moving, and still able to cover short distances at a genuine run!  I’d like to give a shout to a couple of my “fans”.  First is Jen, who unknown to her is the head of my cancer battle PR department, for her dedication to always getting an action shot of the two of us at the indoor track (from last week):

Also my sister, for texting me an amusing, personalized cartoon to commemorate my running during treatment.  Yes, I do love these drugs, they are allowing me to continue living life and telling a good story along the way:

And finally, for reasons I can’t really explain I feel a need to close with a topless photo of myself, showing what cancer treatment has done to my body.  Starting at the bottom, my right hand is pointing at a little green dot tattooed onto me and used as an alignment mark during radiation treatment back in 2018.  The first three fingers of my left hand are pointing to the incisions made when installing my port.  They look like I just scratched myself in the photo, but they're scars which trace the path of the tubing from my port, up and  over the collarbone and into a vein.  The pinky finger is pointing directly at the port, which looks almost like a third nipple.  Good luck getting that vision out of your head.  And finally, my chemo-fro hair do, which is still curly from the first chemo treatments.  I’ve let it grow completely wild, expecting it to fall out again in a week or two.

Some people may look at this photo and remark at the muscle atrophy caused by androgen deprivation therapy, but no, I've always been scrawny like that.

Out of Surgery and Into Chemo

The Battle Begins

Within 24 hours of writing this, I’ll be having the first infusion of my second course of chemotherapy.  Compared to my first course, this will be a completely different cocktail of drugs, for what is effectively a completely different cancer.  It will be the first meaningful shot fired by the good guys in cancer war 2.

For those unfamiliar with chemo, treatment is scheduled as a series of cycles, with each cycle usually lasting 3-4 weeks.  At the beginning of each cycle the chemotherapy drugs are given, and then during the rest of the cycle the body is given a chance to recover before the next cycle.  And generally, it’s the bone marrow and associated blood counts that take the majority of the collateral damage, which limit the drug dosages, and determine the time between cycles.

My cycle will begin with three consecutive days of infusions.  On the first day I’ll be given a pre-treatment of diphenhydramine (Benadryl), dexamethasone (a steroid), famotidine (Pepcid), and if I recall correctly ondansetron (anti-nausea).  These are all intended to suppress allergic reactions to the chemotherapy and limit the initial side effects, and they work very well.  I’m particularly a fan of dexamethasone, as it generally makes me feel like superman for a few days.  Last year, dexamethasone is the reason I was able to go running around the indoor track the day after a chemo infusion.  When it wears off the side effects hit like a bomb.

After the pretreatment comes an infusion of Carboplatin, which is basically a platinum atom with a few other atoms attached to help shepherd it through the system (don’t quote me on that explanation, it’s probably wrong).  In this context, platinum is a heavy metal that is toxic to all cells, and shows a slight propensity for accumulating in cancer cells.  This has been around for decades and is very effective treatment if a bit nasty in terms of side effects.  It’s the Rambo of chemotherapy drugs, “his job was to dispose of enemy personnel... to kill, period! Win by attrition”

That will be followed by an infusion of Etoposide, which is another old chemotherapy drug.  It interferes with the copying of DNA during cellular division and effectively kills any cells that try to divide (again, don’t quote me on that explanation).  This is where chemotherapy can be a bit counterintuitive.  It is more effective against cancers that are growing and dividing at a faster rate.  Because more of the cancer cells will try to divide while the drug is present, a larger percentage of the cancer will be killed.  Slower growing tumors are able to resist treatment simply because the cells are not as likely to divide during treatment.

And finally, I’ll get an an infusion of Atezolizumab which is a relatively new immunotherapy drug.  Here’s my weird way of describing how it works:  Healthy cells express a protein called PD-L1 on their surface that functions as a name tag.  They say “I am Tom”.  The immune system sees the name tag and doesn’t attack the cell, because attacking “Tom” cells would be an auto-immune disorder. This is also referred to as an “immune checkpoint”.

Some cancer cells are able evade the immune system by covering themselves with multiple name tags.  “I am Tom” stuck on the front, back, sides, and top.  There’s no way for the immune system to look at this cell and not thing it’s a healthy Tom cell.  What the drug does is effectively rips the name tag off of all cells, allowing the immune system to go after the cancer cells, and possibly perfectly healthy Tom cells.  To put it more scientifically, the drug is a PD-L1 antibody, and is in a category of drugs called “checkpoint inhibitors”, because they remove the checkpoints that prevent the immune system from attacking.

This all adds up to about 3-4 hours hooked to an IV having chemicals pumped into my veins.  I’ll make sure to have my phone and tablet fully charged.  At to that the 2+ hours driving to the office and back home afterwards, plus any time stuck behind school buses and general commuter traffic delays.  It’s gonna be a long day.

On both Tuesday and Wednesday I’ll get another infusion of Etoposide and some amount of pre-treatment depending on how well I tolerated the infusion on Monday.  This will go much faster, and probably be only a 90 minute visit.

That’s three days of infusions, probably about 6 hooked to an IV, another 6 hours of riding in a car, and however many hours and days of side effects once the supporting drugs wear off.  This week my battle with cancer will be a full time job.

After that I’ll get two to three weeks of recovery time, depending on how fast my blood counts recover, to get ready for the next cycle.  Repeat for six cycles, and I’ll be doing this until around July.  After that, I’ll continue to get the Atezolizumab infusions regularly as maintenance therapy.

Surgery Report

Last week I had surgery to install a power port (no, I can’t charge my cell phone with it) and what is called a double-J stent.  Let’s start with the stent.  No, wait, let’s back up a couple weeks to my liver biopsy.

An interesting aspect of the human body is that if you stick a rather large bore needle all the way into the liver to take a tissue sample, when you pull the needle out the flesh will close around the hole left by the needle and in a very short amount of time will seal the hole and begin the healing process.  There’s no need for stitches or glue or other such wound closures if the hole is small enough.

I was fully expecting the urinary stent would be inserted from the “bottom up”, with my urologist going into the bladder via the only entrance that doesn’t require an incision, finding the blocked ureter, and forcing the stent in.  Unknown to me, my doctors have been talking amongst themselves again and decided this was a better job for an interventional radiologist.

Until a few weeks ago I never knew there were interventional radiologists.  They use radiology (CT scans, fluoroscopy, etc.) to guide them through medical procedures such as placing a biopsy needle right into the middle of a liver tumor.

For the stent, fluoroscopy would be used to poke a needle into my backside and into the portion of my kidney where the urine collects, sort of like sticking a straw into a juice box.  Then a wire would be passed through the needle, down the ureter, and into my bladder.  The stent is then pushed over the wire and follows it down into my bladder.  When the wire is removed, the ends of the stent coil up (thus, “double J”) and help hold the stent in place.  If everything went well the needle would be withdrawn and my body would close up and begin healing with the stent left inside.  If not, the needle would be hooked to an external nephrostomy bag to collect the urine produced by that kidney which couldn’t find its way down to the bladder.

As I noted earlier, this plan was created by my doctors without anybody telling me.  The first I heard about it was from the poor innocent nurse who was giving me the boilerplate explanation and disclosing the possibility that I might end up with a nephrostomy bag.  You could say I broke down at this point, but for the purposes of better story telling I metaphorically jumped up like a scalded cat and dug my claws into the ceiling.

Of course, having been through a similar scenario just a couple weeks ago with the biopsy I expected the radiologist to be able to peel me off the ceiling and explain everything.  I know now that numerous e-mails were exchanged discussing my case, and my urologist thought it would be difficult for him to get the stent in place entering from the bladder, so deferred to the integrative radiologist.  He said nephrostomy bags are relatively rare, and he usually can tell from the scans when one might be needed, and didn’t see anything in my scan that would pose a problem

I like my medical team, but patient communication definitely gets a “needs improvement” mark.  Still, if their time is limited I’d much rather they spend it talking amongst themselves and making good decisions than keeping me informed.  As has happened twice in the past three weeks, I’ll find out about the change in plans and recover, eventually.

And in the end, the stent went in easily, no nephrostomy bag for me!

On to the power port.  This is a device implanted under the skin that consists of a tiny reservoir for receiving chemotherapy drugs connected to a somewhat major vein at the base of my neck.  Compared to finding a vein in my arm for an infusion, the port is the proverbial broad side of the barn.  You can’t miss it.  Also, because it goes into a bigger vein than those in my arm, the drugs are instantly diluted to a greater extent and less like to burn the vein.  After multiple missed veins and two burned veins in my previous course of chemotherapy, I’m looking forward to having a port this time.

The port was also inserted by the integrative radiologist, and this did require several incisions and stitches/glue/tape.  I was under “conscious sedation”, and was aware of him cutting into my skin, though I felt no pain.  I may have remarked verbally about it.  They may have upped my dose of sedation as a result, because I seem to have fallen back to sleep shortly afterwards.

In the end that went well, and I’m slowly getting used to having a bump in my chest and what feels like a string connecting it to the base of my neck.

After the Surgery

I expected miraculous improvement after surgery, mostly because ignorance is bliss.  Just two weeks prior I underwent a liver biopsy and then the very next day walked and ran a combined three miles at the indoor track.  This surgery was going to finally unblock my kidney, how is that not going to make things instantly better?

The good news is that it did instantly stop the bouts of severe, kidney stone levels of pain that could last for several hours at a time and didn’t respond to any pain medication available to me.  As a human being I’m very pleased with that.  As a runner, I haven’t even been able to walk a mile since the surgery, so fitness fanatic Tom is a bit disgruntled.

Let’s back up a few months.  In October I ran a half marathon and didn’t need to stop once to take a pee.  After the race I wanted to ramp up my mileage and try to complete a 15 mile training run before the end of 2019.  That didn’t happen.  The weather got colder, and my bladder got very sensitive to running.

As a result, every mile or two I’d have to hide behind a tree and relieve myself.  Urination was becoming increasingly painful during this time.  There was snow on the ground so hiding behind a tree meant getting my feet cold and wet.  All this sapped the joy out of running.  By the beginning of 2020, running caused blood in my urine, and that’s when the doctors started getting interested in my symptoms.

So my running had been reduced to mostly walking, and distances were reduced to two to four miles.  Somehow, I magically thought a urinary stent would allow me to go right back to running 10 miles at a time.  But no.

If you asked me, the purpose of the stent was to improve my running.  I’m sure if you asked my doctor, he’d say something more along the lines of it was intended to restore kidney function, which is vital when he’s about to pump bag after bag of toxic chemicals directly into my bloodstream.  The sheer fluid volume would otherwise exacerbate the pain and the kidney damage.  Worse yet, reduced kidney function might limit clearance of the drugs and increase toxicity.

Still, I’m human, and I’m bummed that the stent is going to interfere with my running.  There’s two problems the stent poses:

First is that the stent has exacerbated the painful urination.  Previously, I would have rated the pain at 10, or “worst imaginable pain”.  It seems I lack imagination.  The current pain I feel urinating is indescribable, but I’ll try to describe it anyway.  Imagine the worse muscle cramp you’ve ever had.  That’s what my bladder feels like trying to squeeze out the last few drops of urine, and that’s probably more due to the cancer than the stent.  Now, imagine that as the bladder is cramping and squeezing, it’s also impaling itself on the foreign object that is the stent.

I generally pee sitting down now, because it’s difficult to stand upright when the pain hits.  I’ve developed a preference for the handicapped stall in public restrooms, because I can grip the handrails tightly and help hold myself on the toilet.  Like Spinal Tap, my pain dial now goes to 11.  On the bright side, this only lasts for a minute or so.

The second problem with the stent is that even when I’m not peeing it’s still generally irritating my innards, and activity makes it worse.  I suspect my body will get used to it, and perhaps even build up internal callouses to protect itself.  But at this point, I don’t know how much walking or running I’ll be able to do with the stent in place.  I may have to wait for treatment to shrink the tumors to the point where the stent can be removed before resuming copious levels of activity.  I expect I’ll be able to do quite a bit by normal person standards, but not by marathon standards.

So to bring this lengthy post to a quick end, chemotherapy starts tomorrow and let’s all hope that shrinks the tumors and makes life with the stent a little more bearable in the near future.

Reality Brick

Latest News

Since my last post, a PET scan has allowed my oncologist to give me a specific diagnosis (read on for details) and create a treatment plan.  On Wednesday I'll be going into the hospital to have a stent inserted into my ureter to unblock my kidney, which should relieve at least some of the pain I've been experiencing.  While I'm there, they'll also be putting a chemo port in so that the nurses won't have to play hide and go seek with my veins.  That's two minor procedures back to back in the same hospital.  One trip to Framingham and one recovery process for both procedures.  Convenient!

Chemotherapy should be starting next week, exact time and date have not been scheduled.  Finally I'll be able to go into attack mode and hopefully the rest of my symptoms will go away as the tumors shrink.

Symptoms?  Yes I still have plenty of pain, but it's mostly under control.  Despite my suggestion in my previous post that I didn't need opioids, I'm still taking them regularly because I can't take enough Ibuprofen in a day to keep me comfortable.  I must have written the previous post on a good day.  As an aside, if the smallest dose of aspirin is called "baby aspirin", then I'm on "baby opioids".

Despite that, I'm still making the most of each day.  I'm still able to drive around, go for walks (not so much running), and carry firewood up stairs to the wood stove.  Here's a random picture of me posing by the stove with a piece of firewood:

I've also temporarily suspended my attempts to eat healthy.  In fact, I'm trying to gain a few pounds, or at least stop some recent minor weight loss before starting chemotherapy.  Food will be tasteless and I won't have an appetite in a little over a week.  So today I ordered an omelette with sausage and mushroom for lunch, and it was fantastic.  I never knew an omelette could taste "chocolate good", but this one did.

Reality Brick

This post grew out of a conversation with my wife.  I was lamenting that my drafts of possible blog posts were too depressing.  She pointedly asked why they all need to be positive and inspiring?  She's had to remind several people that I'm still on treatment for my original cancer, and should not be considered cured or cancer free.  I admitted to some complicity in this because I grew weary of explaining incurable cancer, and for my own sake I wanted to believe in the improbable.  And so, with that in mind, I'm going to hit you and me in the face with the harsh brick of reality.  Try not to flinch.

A few months ago I ran a half marathon to celebrate the anniversary of my original cancer diagnosis, and everybody cheered.  I had beaten cancer!  However, even at the time of that half marathon I was already having some minor urinary symptoms that in retrospect were the first signs of cancer growing in me again.  We all raised the "Mission Accomplished" banner too soon, not realizing that my enemy was a disorganized band of terrorist cells that had no centralized leadership that could surrender.

My symptoms got worse, and I eventually went to the ER with severe pain that turned out to be caused by a tumor in my bladder blocking my right kidney.  More tests followed.  Eventually I got a specific diagnosis: neuroendocrine prostate cancer.  This is a rare and very aggressive form of prostate cancer that can't be detected using blood work.  I'll need regular scans indefinitely to track cancer activity.

It's not clear to me how this cancer developed.  My oncologist says it started when the normal neuroendocrince cells in my prostate turned cancerous.  However, there's plenty of evidence in the scientific literature that aggressive treatment for normal prostate cancer can cause it to undergo epigenetic changes and transform into the neuroendocrine form.  It's possible treatment caused my existing cancer to change into this new form, but in my specific case there's several reasons to believe this didn't happen.

In either case, once again there is rare, aggressive, metastatic prostate cancer running loose in my body and the diagnosis hit me like a brick in the face.  I knew that I was likely to redevelop cancer at some point, but was hoping it would take a few more years. Let's use this unfortunate development as a teachable moment.  This is the reality of living with incurable, metastatic cancer.  A cancer patient can look healthy, can feel healthy, can even run long distances, but cancer can come back at any time.

In talking online with other survivors, the vast majority of people that have lived with metastatic cancer for 10 or more years have fought back and forth battles where the cancer repeatedly returns but responds to treatment.  Usually in these cases there's a new or otherwise unused treatment available to beat the cancer back again.  Each treatment gives more time for a newer, better treatment to become available.  Some have literally surfed from one new treatment to another for 10 or 20 years or even longer.

The point is that long term survival doesn't usually mean being cancer free the whole time.  It's more like fighting a series of individual wars against the same enemy.  It's very unlikely for any treatment to drive metastatic cancer to extinction (thus, it's considered incurable).  Those cancer cells that do survive treatment are immune to that particular treatment and sooner or later will regrow into tumors.  Thus, the cancer comes back in a more aggressive, harder to treat form.  Shortly after my diagnosis a 10-year survivor on the forum had a recurrence and died a couple months later.  He went from happy and healthy cancer survivor to cancer victim with shocking speed.  An inspiring story of survival came to a sudden end.

This is the harsh truth I've been hesitant to share.  There are real reasons for hope and optimism, but ignoring the reality of the situation doesn't help.  It's reasonable to expect there will be multiple battles, and I'll need the same support and encouragement in each one of them.  Don't be surprised when a battle won is not the end of the war.  I've got a couple more bricks, then we can talk about hope.

Let's throw out some statistics.  For neuroendocrine prostate cancer, about 80% of patients will respond to chemotherapy, but the cancer will return in about 6-18 months.  Statistics apply to populations, not individual patients, but let's pretend for a moment I respond to treatment and get 18 months before the cancer returns.  I'll start feeling much better by summertime.  I'll enter 5Ks again, and hopefully run a fall half marathon.  Continued training over the winter would allow me to run a full marathon in the spring of 2021.  I'll feel fantastic.  Another victory over cancer, and believe me, it would be a genuine victory.  But by fall of 2021 my scans would show an small increase in tumor size.  By winter of 2021 it would be clear the cancer is growing again.  Would there be another treatment available to beat it back again?  I don't actually know.

The five year survival rate is only 15%.  That means 85% of patients don't even live that long.  And that's just for the neuroendocrine cancer.  My "normal" prostate cancer (which is also a rare and aggressive form) could also recur.  I could also have another bladder tumor.  By my oncologist's count I've had three cancers and any one of them could recur at any time.  Forgive me if I sometimes don't like being told "you got this!" or "you look great!".  There was a long discussion on the cancer forum where most men agreed they all hated hearing these things.  But I digress.

I'm done hitting us in the face now.  There is hope.  That 15% survival rate is not a quota.  Oncologists don't shoot patients for fear of having too many survivors.  The trick is to figure out what can be done to increase the likelihood of being a long term survivor.  And generally, survival statistics are right skewed.  Old age is really the only limit to how much a patient can outlive median survival.  For more on this line of thinking, read this piece by Stephen Jay Gould.

A minority of patients get exceptional responses to treatment.  If you consider my neuroendocrine cancer as a separate cancer, then I've already had an exceptional response to treatment for my other prostate cancer and that treatment is still working.  There's every reason to believe I'll get an exceptional response to treatment for the neuroendocrine flavor.  I believe that exercise, maintaining a healthy weight, and having a good laugh regularly all help with response to treatment and survival.  At the very least, they all help in coping with treatment, and treatment can't work if you can't tolerate it.

I've also held back a teeny weeny detail.  In addition to chemotherapy, I'll also be getting a relatively new immunotherapy drug.  I don't have any statistics on this drug.  If it's like other immunotherapy drugs, then it only provides a significant benefit in a minority of patients.  But, when it does provide a benefit, it can be nearly miraculous.  The drug cocktail I'll be receiving is also used for small cell lung cancer patients.  My oncologist had a lung cancer patient that took this immunotherapy drug for two years and the scans couldn't find any cancer by then.  They stopped treatment and she lived for another three years before dying of a heart problem.  She was in her 80s, who knows how long she could have survived her cancer if she was younger.

Here's another thought:  Laughter produces endorphins.  Endorphins stimulate the immune system.  Shortly I'll be on immunotherapy that uses the immune system to fight cancer.  Ergo, laughter helps me fight cancer!  I'm really not silly, I'm a cold and calculating murderer of cancer cells.  Bwahahaha.  Seriously, one of my strategies is to laugh so much I'll be late for my own funeral.

It's unlikely I'm at the end of my road.  Most likely I'll travel a bumpy and rocky road for quite some time.  There's even a small chance it will be a long smooth road.  Anything can happen.  Hope comes not from ignoring the negative possibilities, but from realizing the worst case is not guaranteed, and the best case is not impossible.  We literally don't know how well immunotherapy could work.  Will my scans show no cancer two years from now?  I just don't know. I really just don't know. I'm afraid I really just don't know. I'm afraid even I really just don't know. I have to tell you I'm afraid even I really just don't know.

And I quoted Monty Python in another blog post.  Bugger.