Challenges

July 2019
There's nothing like a terminal diagnosis to remind you that you have waaaaay too much stuff. And if you do not do something about it, some of the people you love and adore are going to be lumped with the enormous task of sorting it out.  I mentioned in the previous post that when death seems quite imminent, you can focus on the task of getting rid of stuff.  But when a new treatment pushes back your own personal "deadline", the urgency of the task wanes considerably. Currently I do not have any solution to that.



The changes in forecast lifespan have recurred throughout my time with cancer. Sometimes death seems like a speeding road train with its headlights on high beam, tail-gating you. At other times you are aware that the truck is somewhere behind you, but your focus is no longer in the rear view mirror, but on the road ahead.

When I started with hepatocellular carcinoma (HCC), successful surgery seemed like the end of my immediate thoughts of the threat of death. Then, when metastases were detected a year later, treatment options, survival and end of life care come to the fore. At that time there was only one drug treatment option. After I developed a toxic response to that drug I knew there was nothing else for me. But then, just before Christmas 2017, I was told that there was now one other possibility.  A new drug, still undergoing clinical trials. The challenge for my specialist was figuring out how to access this new immunotherapy drug, just beginning to be used for HCC. He was no doubt very busy over the Christmas holiday period, writing up applications to various bodies to obtain access. I was not eligible for the ongoing clinical trial as recruitment had just closed. But he made a case to the drug company for a compassionate access program.

That drug, nivolumab, was delivered by intravenous infusion. This meant I needed to be in my home town every two weeks for the foreseeable future. Never mind though. I developed no unmanageable side effects and we could learn to plan around the fortnightly trips to the IV Lounge. Life became normal again. Except for one afternoon a fortnight, I virtually forgot I had cancer. Things were sweet for about 15 months. Then a tumor marker on the blood and a CT scan suggested that my good buddy, nivolumab was no longer working for me. For several months it was not clear if I needed to divorce nivolumab and enter into a new marriage with the new kid on the block lenvatinib (Lenvima). This drug worried me. It was a brother drug to sorafenib (Nexavar) which I'd only been able to tolerate for 10 days because of a serious adverse reaction.

You start to analyse and discuss the research studies about your drugs: what trials have been undertaken, are the results available yet, what is the side effect profile, what is the effectiveness (Overall Response Rate, Time to Progression, Progression Free Survival).

You set up a Google Alert for hepatocellular carcinoma and the drug you are on, so you can keep up with the latest health care news.

You weigh up the pros and cons. What is the probability of the drug working vs the probability of intolerable side effects? Despite these analyses, you have no way of predicting your individual responses to the drug. Which group will you fall into - the group which did gain a benefit from the drug or the group that didn't? The group which experienced bad side effects, or the group that didn't?

I was lucky to be offered lenvatinib which had been placed on the Australian Phamaceutical Benefits Schedules only days before. Instead of paying AUD9,600 a month for daily capsules, the Australian Government subsidy meant I would pay just AUD6.50.

So life with cancer is a series of new decision points, decisions that must be made with imperfect information. It is a special kind of emotional roller coaster, with some smooth bits in the middle.

My partner and I approached each consultation with the specialist with a list of questions and discussion points we'd prepared. We realised beforehand that there would probably be no clear answer to some of the questions, but we still had to ask.

We took copious notes and discussed them afterwards. Invariably one of us would have picked up points the other had missed. There's such a benefit from having two pairs of ears.

In the end you just have to decide what seems right at the time.

Whether you see an oncologist or a hepatologist depends on who you can develop a good rapport with, more than anything. I used to think that oncologists want to push you towards the most aggressive treatment regimes and would not support your decision to stop pointless treatment. But perhaps not all are like that. I would like to see the cancer under control of course, but not at any cost. The quality of my life is far more important than the quantity.

I was also very fortunate that the public hospital HCC clinic I attended provided access to a specialist nurse by phone and email. If a new side effect appeared, the nurse was interested and responsive, suggesting ways of managing it and arranging a prescription, if needed. She checked on me weekly and also helped coordinate between the hepatologist and my general practitioner (primary care physician) and any other specialists involved in my care. Best of all she encouraged me to get out there and enjoy a normal life.

This nurse liaison service is quite wonderful. It's a service not so evident for all those attending a private clinic, despite the large difference in out of pocket costs. Cancer care seems to be more disjointed in the private sector than the public sector, based on my own experience and that of friends and acquaintances. Things happen to patients between consultations. People living with cancer need a way of being supported in a more continuous manner by people who understand and are trained in this field.

Post script written four months after the above (Nov 2019)

In late June I'd decided to have a go with the new kid on the block, lenvatinib and this was going well. The tumor marker was coming down, no new tumors, perhaps slight decrease in size of some of the existing ones. I felt well.

Then I didn't feel well. Backache, chronic cough, weight loss, fatigue and breathlessness, increasing throughout August 2019. Then a CT scan revealed "ground glass" - white opaque areas in my lungs. Either I had pneumonia or pneumonitis, an immune related inflammation of the lungs. Another hospital stay, this time for 3 weeks. Firstly they had to determine which was the cause, pneumonia or pneumonitis. The treatment for pneumonitis, steroids, could have a disastrous effect if it were an infection. I spent 10 days getting pumped with antibiotics and tested for every kind of lung infection, all the while getting sicker and sicker, in respiratory failure on 15 litres of oxygen a minute, bed bound. Finally a specialist decided it was time to start steroids!

And I slowly began to improve, get my appetite back, sit out of bed, take a few tentative steps. I had pneumonitis, believed caused by a delayed reaction to the previous drug, the immunotherapy drug nivolumab, which can over-activate the immune system so that it attacks your healthy body.

Seven weeks later, after lots of support from family, friends, health professionals, a regular home rehab program of exercises and walking, I no longer need the oxygen around the house, just when exercising and walking longer distances. I am getting better.

I'd had to stop the cancer drug lenvatinib when I was in hospital as I was so ill. Have now resumed it and am back on track.

How it hits you

Like most people who are, I never expected to be diagnosed with cancer. But I did and it was both a surprise and, strangely,  a relief.

At 48 my lungs were badly damaged by severe pneumonia, I spent a month in intensive care and returned to work after 4 months sick leave. I learned to manage my chronic lung disease, joined a support group and eventually came to lead it. I thought that having acquired this lung condition, I would not get cancer. In psychology this is called magical thinking - superstitious thinking. And it did not protect me. But it certainly ended up preparing me well for living with a terminal illness.

I did not have any of the major risk factors for cancer. I'd never smoked, barely drunk much alcohol, wasn't obese (a bit overweight, if I'm honest). Thanks to pulmonary rehabilitation after my pneumonia, I exercised regularly, within the limits of my lung condition. I'd had no occupational exposure to known carcinogenic agents, apart from parents who smoked. I had no close relatives who had had a cancer diagnosis. I'm a keen family history researcher, so I know the cause of death of many of my relatives.

Liver cancer usually has no symptoms until quite late in the piece, so I was lucky that mine did  - or the tumour might have grown much larger and been too large for successful surgery. What I did have was severe pain on my right side, just under my rib cage. It began one evening just after dinner, a month after we returned from a fantastic 6-week camping trip into the north of Australia - including the Kimberley, the Top End, and Kakadu National Park. We phoned up the home visiting locum GP who examined me and suggested we go to the local public hospital emergency department. It could be appendicitis, he thought, or a gall bladder attack. Not urgent. The hospital could do some tests to pinpoint the cause.

As I was getting ready to go to the hospital the world became yellow and dizzy, and I blacked out. I came to on the floor.   My partner Tom had managed to break my fall. He'd called an ambulance as he now couldn't risk taking me by car. The ambulance took me to hospital, no flashing lights or sirens. Arriving by ambulance on a Friday night I was seen remarkably quickly in the ED. A CT scan revealed a growth of some sort on an outer lobe of my liver. It looked to be about 25mm across. It had been contained within a capsule which burst, along with an adjacent blood vessel, causing internal bleeding, hence my blackout and the pain.

The doctors arranged for a hospital bed and surgery as soon as possible. I was made comfortable with pain killers until surgery could take place - about 36 hours later.  My son lived in Malaysia and managed to arrange a flight to Perth, arriving not long before my surgery.  After the surgery I was told it might be a couple of weeks until the pathology results became available.

It turned out to be 5 weeks. By this time I thought the tumour was surely benign, otherwise I would have been called in for the results much sooner.  The section cut from my liver (segment VI) turned out to be 120 x 120 x 50 mm, the tumour being a nodule about 50mm in diameter.  Apparently you can lose about 75% of your liver and it will regenerate. I'd lost only about 5%. Cruisey.

I was surprised to discover that this growth was in fact malignant, a hepatocellular carcinoma (HCC) or  hepatoma, the most common type of liver cancer. I recovered well from the surgery and was told the surgeons were confident that the whole of the tumour had been resected. Because a blood vessel had ruptured with the tumour capsule, there was a chance that the cancer could have spread elsewhere in the body. So I would be monitored quarterly by blood test and CT scan.

Every 3 months I attended the HCC clinic and saw so many very ill and frail people in the waiting area. I felt like a fraud, taking up valuable hospital resources. At each consultation I learned more about HCC and my particular situation. My partner attended each of these specialist visits for a year, providing another set of ears, helping take notes and ask relevant questions. Since all was going so well, I told him it was OK, I could go on my own to the next one. So 14 months after the tumour had burst, after the "all clear" on CT scans and blood tests, I received the surprising news that metastases (secondaries) had been picked up on the latest CT scan - in my lungs and in the abdominal cavity, the peritoneum. Too many tumours in the lungs for surgery.

In Australia there was just one drug approved for liver cancer, Nexavar (sorafenib). I started on that but had to stop after just 10 days because of a  severe adverse reaction. Without any other treatment options the specialist suggested I do some of the things I've always wanted to do - at least in the next six months, when my quality of life should be OK. He said he didn't really know how long I might have, but that given my situation, my overall health and other conditions, he thought maybe I had about a year.

I started "getting my affairs in order". Spoke to a palliative care nurse, an independent funeral director, an eco-coffin retailer, the operators of the natural burial ground where I'd like to be buried, a venue for a memorial event and another for a wake. I discussed the 50 questions on the Your Life Wishes cards with my partner and my son, and documented my wishes, revised my will, filled out a personal affairs record book and reviewed my appointment of enduring  guardians and attorney.

Shocked
What was I feeling?  Well, to be honest, very shocked at first, when told about the metastases. I think I babbled on to the specialist (who broke the news to me in a very sensitive way). I told him I'd hoped to be one of his "happy ending stories". He'd already told me how few people survive liver cancer. He knew I could google that stuff for myself.

Overwhelmed
Then, once I realised how much I had to do to get my affairs properly organised, I felt rather overwhelmed by the size of the job. I wanted to make things easier for my son and my partner after I've gone. I wanted to give away books, clear out things - either dispose of stuff I really don't need and give some items to special people in my life.

Twenty months later I'm still here - thanks to some excellent health care and the availability of some new drugs. Due to my continuing good quality of life, I've only just made a start on the mammoth task I set myself. Honestly, I've barely touched the surface, because my death has receded into the medium distance again. These tasks do not seem to have the urgency they had in late 2017. I can look towards the medium future, plant seedlings, plan some trips again, forget about that last final one.

Relief
I also felt relieved. I realised my finances were going to be OK. If my life is to be reduced in length my superannuation fund will surely not run out, something I had feared for years.  And I will probably never develop dementia, a state I would hate to impose on those around me. I won't lose so much more hearing that I am cut off from friends, family, music and birdsong.

I have a pretty good idea what I'm likely to die of, and some idea of what that is going to be like.  Though of course you can never really know.  This helps many people live their lives with that uncertainty taken care of. I cannot say that topic has ever kept me awake at night, but it's still a kind of relief.

Sadness
I feel sad too. Sad that I will probably not live to see my grandchildren grow up. Sad to leave the people I love, my partner and my son particularly.  My son has already had some traumatic events in his life and I feel bad about inevitably adding another. Is that too vain to imagine?

Elephants and other things

There's a bit in the way we talk about cancer that annoys me.  Here are some of my pet peeves.

For a start I don't like the term "cancer journey"(trite) and I hope no one EVER says about me "she lost her fight against cancer on..."

When you go on a journey you usually end up somewhere nice. Cancer is not a journey. 

... the words of another person with cancer (whose name I have unfortunately forgotten)

It's true that everyone's experiences with cancer, cancer treatments and supports vary widely. So it's not a package tour, that's for sure. It's also true that the destination is the same for many. Dying. Not for all.  But for very many with liver cancer.

Survival rates vary. The medical profession talks about 5-year survival rates when comparing different treatments. The 5-year survival rate for liver cancer (hepatocellular carcinoma, HCC) in Australia was 18% in 2015-16 when I was diagnosed. So that means less than 1 in 5 will still be alive in 5 years.

Survival rate is improving though, thanks to more research and new treatments. But the diagnosis rate is increasing too.

HCC is the 15th most commonly diagnosed cancer. More common in men than women, more of a risk for with people with chronic hepatitis, liver scarring (cirrhosis).  I'm not male and have neither of these, nor indeed any other risk factors. Random mutation the specialist told us.

There are not many treatment options. Some people will be eligible for surgery or ablation. I had surgery initially and that successfully removed the tumour in my liver. Unfortunately secondary tumours developed in other parts of my body, mainly my lungs. Too many for surgery.

Drug wise there are two approved medicines in Australia aimed at treating cancer (May 2019).  Both approved drugs are targeted therapies that interfere with cancer cell metabolism. They cannot "cure" the cancer, merely try to stop it in its tracks, preventing further tumour growth. The second, lenvatinib (Lenvima), has about a 50-50 chance of effectiveness. But it can easily give you some nasty side effects too.

The immunotherapy treatment I've been lucky to access is not yet approved for liver cancer in Australia. I have been fortunate to access to it through the drug company's compassionate access program. Thank you, Bristol-Myers Squibb. I was also supported by Sir Charles Gairdner Hospital in Perth, Western Australia. Thank you, IV Lounge.

Back to my pet peeves.  The medical professional has a very odd way of referring to the growth of cancer tumours: progression! Really? One of the measures of the effectiveness of a new cancer drug is "Progression Free Survival" - how many months did you live on this drug before the cancer got worse?  When the cancer gets worse it is hardly progress. Sure it is progressing towards death, but not the most thoughtful expression from the patient's perspective.

I also don't like the term "cancer sufferer". Does that ever drop you in the victim box and leave you there.  I'm  not asking Why me?  I'm more of a Why not me? person.  Get in there, find out all you can and figure out what you can do, and what you cannot.

My hepatocellular carcinoma (HCC) diagnosis came in 2016. So here I am in 2019, three years later.  Living the life.  With secondaries in my lungs. Will I be here in 2021? Will my number be up when the five year period is up? Who knows. Maybe not. When I die - and I surely will - I've left instructions about how to let friends and family know: in the paper, by email, phone and on social media.  My partner Tom and my son Khalil  would not dare to say "she lost her battle against cancer".  I'll be back to haunt them if they do.

People, it's not a battle (or a journey). I'm not fighting anyone or anything. I'm living my life as best I can, just like you. The language or war and conflict has no place in a discussion of life and health.

And finally.

Yeah, the elephant. As a society we need to get better at talking to people with cancer. I know, I've been as guilty as the next person. Quite some years back I visited a relative at home. She was nearing the end of her life and had cancer. (I had yet to join that particular club.)  I am ashamed to say that I spent a fair bit of the visit talking to her daughter about anything but cancer or her mother's health. Heaven's above, the sick relative was not deaf or mute.

Why didn't I talk to her about how she was going? Maybe I did not know how to. Felt embarrassed. Had never faced this situation before, fearful of saying the wrong thing. So avoided the elephant in the room.

This experience flipped back on me in the early days of my first unsuccessful treatment of the metastases. I had terrible side effects to Nexavar (sorafenib). Particularly hand and foot skin reaction, which sounds like a bit of a rash, but is much worse. Your fingers and toes become red, swollen and extremely painful, all the time. To touch ANYTHING is excruciating. I used white cotton gloves all the time on my hands to protect them a bit. But I could barely take down my pants to use the toilet, brush my teeth, cut my food, use my inhalers. I went from OK to invalid in a few days. These pictures are not my feet but mine looked similar.

It's a sign of toxicity, so after 10 days on this drug I had to stop and face my "final run".  During the 10 days of sorafenib, at the height of the pain and disability, we went out to dinner with some good friends. Perhaps this would take my mind off the pain.  At home my partner and I spoke much about cancer drugs, death, funerals, side effects, palliative care, survival statistics etc. We could barely think about anything other than cancer.

At dinner our good friends could not face the elephant in the room. Our friends, who had faced cancer themselves, could not mention it for more than a minute, it seemed. Even when my partner had to cut up my meal in front of them and I had to wrap a cloth around the cutlery to further protect my hands from the pressure.

Is it that cancer reminds us all about the temporary nature of life, that we all face death (though some more imminently)? Are people are frightened that if they raise the topic they are going to be bombarded with nothing but hospital and medical topics?

I'm not sure how we do it but we've got to get better at talking about cancer, because a hell of a lot of people are going to get it. But we should avoid those hackneyed terms about journeys and fights.

The Death Cafe movement  encourages people to feel more comfortable talking about death and dying by hosting safe conversations in public places like cafes and bars. I have attended the Perth Death Cafe on several occasions and found it to be a marvellous way to explore ideas. Not everyone attending has received a bad prognosis. Some are still getting over the death of a close family member or friend. Some are just wanting to get their life ready for the inevitable phase, when it comes.

Gratitudes

What I am grateful for, yes, grateful. This includes finding my cancer buddy Sam.

I started this list in August 2018. I'd been told 10 months earlier that I had about a year left, as there were no other available treatments for metastatic liver cancer. But later in 2017 a new treatment was found and I started it in January 2018, possibly pushing my "final run" out - if it worked. It seems to have worked for 16 months but may be failing now. Even so I am incredibly grateful for the opportunity to be the first in WA to access nivolumab immunotherapy for this type of cancer. It has been a treatment with very manageable side effects.

I want this list read out at my funeral - which I started planning in late 2017.

I am so grateful for the love and support from family and friends. Without this I could barely have managed the past couple of years, however strong you think I am.


My loving partner Tom and my caring son Khalil. Since the cancer was first diagnosed in 2016, both have been pillars of kindness and support. Tom has attended most medical consultations with me, contributing constructively to the discussion with doctors and helping me with decision-making afterwards. At my request he has gently encouraged me to keep up with a daily walk as long as possible. Khalil has kept abreast of medical developments - thanks to WhatsApp - and made so much time for me in his busy work and family life, letting me spend as much time as possible with his delightful sons, whom I love so very much.

Thank you so much, Khalil and Nina, for making me a grandmother. I did not know just how much fun that would be - until it happened. I do hope the boys will remember me. I have had so much pleasure spending time with them as they have grown and developed and really appreciate the relationships I have with them.


I’ve acquired some cancer buddies over the course of my time with cancer. There’s a strong connection between us, even if we have a different type of cancer, have experienced different treatments or are different ages. In particular thank you Sam for your friendship. Our shared love of plants, gardening and the bush has been so enriching.

I am also eternally grateful for the amazing care I have received at Sir Charles Gairdner Hospital in Perth, Western Australia. A great public hospital that has saved my l life twice, once when I was 48 and again when I was 66. My hepatologist and his clinical nurse consultants, Megan Collins and Candice Ingwersen have been so responsive and supportive over the past 3 years. The nurses at the Intravenous Treatment Lounge were caring and efficient during my fortnightly visits for immunotherapy. Thank you all.


I have had some amazing opportunities in my life and am so grateful for these:


A scholarship to Camberwell Girls Grammar School in Melbourne where so many doors opened – allowed me to follow my passions to university. Without this scholarship my parents could not have afforded private school education.


My life has been so much richer for having met my former husband, the late Syed Ibrahim - and of course for having given birth to, and raised Syed Khalil, the son we made together. I am glad that I lived in Malaysia as a member of an extended Malay family. Though not always easy, it gave me a chance to understand the Muslim religion and the Malay culture from the inside and to “properly” grow up, away from my own family, and long before the internet and cheap international phone calls.

In the 1970s as the only psychologist with a Ph.D. in Malaysia, I was able to work in new fields - drug rehabilitation, clinical practice and universities there. There were no other psychologists to learn from, but many others who influenced my understanding of these roles.


With friend On Su-ming we opened Malaysia’s first health food shop, Sunflower, in Ipoh, of all places. With another friend Sandra Lee, we established a child care centre, Sesame Corner, for pre-school children, based on education through play, unlike anything available in Ipoh at the time, but not unlike many Australian kindergartens.


I’ve had lots of adventures. I’ve been scuba diving on some of the most beautiful coral reefs off the west and east coasts of Malaysia. And I briefly piloted a Piper Cherokee and helped land it at Melaka airport. Very exciting. How amazing it has been to visit so many parts of the world – from Japan and Vanuatu to Scandinavia, Italy, Switzerland, England, Scotland, Wales and Ireland.


I am also glad I've had opportunities to explore closer to home - in many parts of Australia and New Zealand. To camp in some of the most beautiful places in the world – in remote Western Australia, South Australia and the Northern Territory with friends from the Subaru Club. To discover the Perth Hills with the Hills Hash House Harriers – not that I could ever run. The bush walks have been wonderful, and so has the company.


(I think) I am glad to have become addicted to family history, thanks to the inspiration of cousins I got to know after moving to Perth. It has been the most absorbing of interests, motivated by my love of mystery and exercising my research and analysis skills. To really understand who I am, I have learned about those who have gone before me. To my friends at the WA Genealogical Society, especially the Irish group and the Western Ancestor journal – thank you all for your fellowship and support.


I am ever so thankful that I was born at a time when university education was becoming more accessible for women and arrived in a loving family that did not hold me back - even though neither of my intelligent parents had had similar opportunities.

And to be alive when the internet developed, helping to appease my endless curiosity about the world - and more than satisfy my appetite for pictures of kittens and people doing silly things.


I have appreciated the mentors I had in the WA public service, particularly Jenny Bunbury, Jane Brazier and Heather Brown. They encouraged me and supported my re-invented career in Perth from 1986, and again, in 1998, after severe pneumonia left me with permanent lung damage.


To my friends in the respiratory health community in Perth, thank you for your friendship, encouragement and support, especially the Institute for Respiratory Health, and the members of L I F E, the lung support group I joined in 1998. I went on to lead this group from 2009 with founder Edna Brown, then, on my own after she became very ill and passed away. Thank you Sal, June, Raema, Sarah, Tom, Mary, Jan, Rosemary, Gaye, Ina, Irene, Elaine.


For your support and fellowship I thank leaders of other WA respiratory support groups, particularly Melissa Dumitru, Jan Thair and Janelle Griffiths.


I have been fortunate to live in a caring community among the purple jacarandas of West Leederville. My neighbours became friends and their friendship has sustained me. Thank you Jan, Michael, Pat, Gill, David, Jeanette, Raymond, Melita, Christine.


I have been so fortunate to have been able to walk away from the paid workforce at 55 and spend more than a decade in a new career as an active volunteer for many organisations: as a health consumer representative for the Health Consumers Council, the leader of a self-help group for people living with chronic lung conditions, leader of the Irish Special Interest group at the WA Genealogical Society and as a simulated patient in the University of Western Australia School of Medicine. So much fun and a genuine sense of satisfaction.


Two factors brought me to the lucky position of an early retirement: my late ex husband Syed Ibrahim’s fair and reasonable Muslim divorce settlement and my own relatively frugal life style (Sorry Khalil. Turns out I didn’t have to make my funds last as long as I thought). So in an odd way I am glad cancer has shortened my life so that I could be reassured that my superannuation would be enough to last me out!


I am strangely glad I won't live long enough to get dementia or severe hearing loss that would both separate me so much from family, friends and community – from people.


In the words of Albert Facey, I have truly had a truly fortunate life. Thank you all for being a part of it.

Yet another cancer blog!

Yes, another cancer blog.

Sometimes reading someone else's story can help if you've just got the news about your cancer - or someone else's. And it often helps the blogger to work out their response to this big change to their otherwise peaceful life, and get certain persistent thoughts and ideas out of their own system and into the ether-verse.


My basic story. I am starting this in 2019 at 68, two and a half years since I was first diagnosed with primary liver cancer, hepatocellular carcinoma, HCC for short.


Since January 2018 I have been posting a short report and photo each fortnight from the intravenous treatment lounge on my Facebook page. This was intended to update friends and family on my immunotherapy treatment. But thoughts kept whirling around in my head at 4am and they were not concise enough for Facebook.





At the moment my plan is to cover these topics. Perhaps I'll think of more before I'm done.

• Impact of cancer on your life, and those around you
• Gratitudes - what I am grateful for, yes, grateful. This includes finding my cancer buddy Sam.
• Big challenges I've encountered: facing death, getting organised for that, finding good health professionals, managing side effects,questions to ask, imperfect answers, emotional roller coasters, balance in your life
• Pet peeves - avoiding the elephant in the room, the language of cancer