Merry Christmas to all and to all a good night...

No, I did not drop you off of my annual Christmas letter list. I just have not gotten around to sending one since 2008. But I will get one out this year, I promise. Maybe not for another month or so but...

So the dogs and I drove up to Sylva, NC on Christmas Eve where I had rented a cute little house in Dillsboro (kind of a Sylva suburb) with just enough room for me and the dogs for Christmas Eve and Christmas Day. Despite grim weather predictions, the drive up was lovely. We arrived in time to settle the dogs and make it to the First Baptist Candle and Carol service (me that is, I left the dogs in Dillsboro) and afterward to the usual open house at the home of parents of high school friends where their extended family (and my extended high school friendship circle) gather on Christmas eve. And after that to the next extended family gathering, this one a bit more compact and the children and grandchildren of another high school friend. It was all lovely. Significantly, First Baptist is between pastors at present and as a result the design of the Candles and Carols service was up to the congregation. They decided to revert back to the original design - just scriptures interspersed with carols, lite by candles, with a pleas for funds to support service to local residents in need and a choir special or two. It was lovely. And short. which we all appreciated.

the following day 3 to 12 inches of snow were predicted, and by the time I was up and stirring at 8ish there was already at least an inch on the ground. I decided to make a calculated gamble that I could load up the car and get over Cowee mountain before the snow froze and thereby get back to Atlanta on Christmas Day. The alternative seemed to be maximizing the value of my rent by staying through Christmas Day as originally planned, but risking letting the roads freeze and being unable to return to Atlanta for several days. While I greatly appreciate several high school friends who offered me a spare bedroom for my own use, or a basement for the temporary dwelling of my dogs if my stay was forced to exceed the duration of my rental reservation - the fact that my next Chemotherapy (Avastin) appointment was on Monday Dec 26 made it highly desirable to return to Atlanta on schedule.

So i packed up the car while the snow continued to fall thickly all around. By the time I had the cars loaded and added myself and the dogs and started out, there were likely an additional couple of inches of snow on the ground. And it continued to pile up as I drove out of town and headed up the mountain.

The drive was beautiful. The snow was falling so thickly that distant vision was limited. Fortunately all the way over Cowee mountain the traffic was very limited, so it was easy to keep large distances between cars. But I had no trouble - no slipping or sliding. Anyone who has traveled over Cowee mountain and admired the view from the large drop offs will recognize this as an excellent thing. My usual traveling speed of 55 - 70 MPH was reduced to something more like 20 - 35 MPH all the way through North Carolina and the first part of North Georgia. Around Tococca, Ga the snow turned to rain, and shortly thereafter the roads cleared and travel returned to normal speeds so that I arrived home in Atlanta by early afternoon.

Temperatures hovered around freezing the whole time, however, and within a couple of hours of the time the dogs and I re-established ourselves in the house in Atlanta snow began to fall here as well. By Sunday morning the roads were iced in, the yard was covered with snow and I did not bother to try to leave the house until Monday when it was time to depart for chemotherapy. Fortunately the roads had cleared and the snow and ice in the yard had diminished.

And today the snow and ice in the yard is largely diminished - almost gone in fact.

Now I know that about now those of you in Minnesota and Boston and New York and Canada and other points north are thinking "What is the big deal?" But trust me, down here in Dixieland a white Christmas is a rather rare commodity. This was the first white Christmas in the mountains in, if I remember the news correctly, several decades, maybe even 50 years. And the first white Christmas in Atlanta since sometime before the turn of the century.

It was all very very beautiful, and we (Jake, Balsam and me) enjoyed very much our low key white southern Christmas. We spend a lot of time eating tomato soup full of crumbled corn bread, drinking cinnamon flavored hot apple cider, and thinking happy thoughts. I spent a good bit of time reading the load of Christmas cards and letters and often giggling over various reports from you and your families. Thanks for keeping me informed.

The snow and ice are largely gone now, but enough remains to make the trip up and down my back stairs a bit treacherous. Fortunately I make it rarely but the dogs make that trip multiple times a day. But it is lovely. Sorry I did not catch a photo for you.

Another avastin dose down, 3.5 months to go...

I had another Avastin dose today. This will continue every 3 weeks through March 21. The good news is that my blood pressure was excellent today on my current medication - with a systolic under 130. High blood pressure is a frequent and problmatic side effect of Avastin, and I have had to go on medication for it, but appear to be doing fine on my current medicine.

My hair continues to grow but (maybe I imagin it) much slower than before chemo. I am not complaining. I am so happy to have any hair at all again!

Jake, my 14.5 year old pound mutt with the tumors in his live and lungs, continues to do surprisingly well. He sleeps a lot, but then he is more than 2.5 years beyond his predicted life expectancy so... He hangs out closer to me, and seems a bit slower, and continues to slowly get skinnier - but otherwise he just keeps trooping along, sweet as ever and apparently happy. Sorry to leave you hanging for so long. I am renting a tourist house in Sylva on Christmas so I can take the dogs with me instead of boarding them, but otherwise they, and I - we are all doing well.

I am taking a lot of personal time off last month and this one. BEtween the time off work and the increased energy I am finally makeing real progress in catching up on the mail, filing, paperwork, and just plain stuff that piled up around the house over the course of my chemo. Hopefully by the new year the house will again feel more like a home than a ware house.

Otherwise no real news to report. Hope all your holidays are happy and healthy.

I am doing fine but the dogs are having problems

Had my most recent doctor appt today and all looks well. I will have my next Avastin treatment on Monday. the original schedule was delayed a week because I had to give a lecture out of town last Monday.

My first 3 major professional deadlines since chemo all came in a bunch over the last 3 weeks and I managed to meet them all. Although it required working over time and some on weekends, but even that was good since it provided proof that I can do that again. But hopefully not too often.

Now for the bad news. The dogs went in for their vaccine updates and, for Jake, his senior dog exam which usually consists just of lab tests. This time his liver enzymes came back very abnormal so he went further for ultrasound examination of his liver and lungs. Bottom line - multiple tumors in his liver and at least one large one in his lung. Not good. He is also getting skinnier every week and looking very boney now.

I decided against surgery or chemo. It would not be curable. He is already nearly 2 and a half years beyond his predicted life expectancy. I can't see putting him through any of that. So we are all making an extra effort to make Jake's life as good as possible for the remaining time, which based on the rate at which he is losing weight will not exceed the winter. Sad but inevitable. He is a very sweet dog. And he has had a very good life for a pound dog.

Update - avastin, progress and HAIR

Yesterday I had my most recent Avastin treatment. Things went smoothly and the next one will be 4 weeks from now instead of 3 weeks. I had to delay it a week because of a professional committment. Which tells you I am back at work full time and slowly increasing the work load and once again meeting deadlines and honoring committments.

Really, it is reminding me that the ZEN days of chemo when I had to let go of everything and just live in the moment, watching America's Next Top Model and Project Runway and not worrying about anything beyond whether I should invest in some 4 inch heels after I finished chemo were... well they had some aspects to recommend them.

Living in the moment is not that bad.

BIG NEWS - this coming Saturday Oct 16 I have my first appointment for a hair cut since my head was shaved last December. Not that there is really much to cut or that I really want it shorter, but at least it will be intentionally shaped a bit. And mostly, I just like the idea that I have enough hair again to think about cutting it! YEAH for small victories.

Sorry for being so slow to update

In response to a couple of complaints that I have not updated my blog, i apologize. I am slowly progressing week by week, but since that means I am now working a full 40 hour concentration week at work, I still tend to have limited energy on the weekend and spend a lot of time zoneing out to ensure adequate energy to make it fully through the work week.

I continue to do well. I still get Avastin every 3 weeks - last time yesterday - and will continue to do so through early 2011. And I get physical exams every 6 weeks - next one tomorrow - as well as laboratory testing every 6 weeks - next time in about 3 weeks. And periodic CT scans.

The results of every thing continue to be good - the labs are all normal, the CA-125 (a marker for ovarian cancer that was over 250 before my surgery) continues to be below the normal range. The CT and exams have been without any evidence of disease.

In other words, all things are good.

The recovery continues to be better week by week, but still slower than I would like. I am really working full time now - 40 hours a week of strong concentration - but have to titrate my efforts during off hours to be able to sustain that. My hair is back - not long enough for any intentional shaping, and a rather dull color halfway between grey and dishwater brown. But who can complain?

It has been a busy couple of weeks, with my Aunt Marian in and out of the hospital and needing more assistance from me, a niece moving in and another visiting for a weekend. But that has all been good and it is nice to learn that I can now gear up to extra stress when necessary.

Nothing too exciting to add - but in this world that is pretty good. Hope you all are well. Thanks again for your support.

New CT, Avastin next Monday

I had my most recent CT last Thursday - still no evidence of disease. And I have my next dose of Avastin on Monday.

This whole recovery process is slower than I had anticipated. I am better every week, but still running out of concentrating ability by Friday and having to carefully titrate my physical and mental energy investments. This is normal, I am told / was warned by my doc and chemo nurse and other women who have been through the same process. As long as I am having good outcomes I try not to complain.

Hard to believe that September is just around the corner. Where did the summer go? Since I don't tolerate heat very well these days, for once I am not sorry to see the summer go.

No evidence of residual disease & genetic testing results

My sister asked when I will know if I am in remission, and several of you have asked for updates.

At the moment, just over 9 months after surgery and more than 3 months after finishing the standard chemotherapy, I have no evidence of residual disease by physical exam, CT scan, or blood test (CA-125, which is not reliable for everyone but was elevated in me prior to surgery, less so but still high after surgery and before chemo, and has been in the normal and very low range very since). That is good news. That is, in fact, as good as it can get at this point.

I am still taking my investigational drug, Avastin, every 3 weeks through next February or so. I have developed high blood pressure as a result of the Avastin - a common and some times dangerous complication. But so far my blood pressure is adequately controlled with my medication, so I can continue the Avastin hopefully through the end of the intended course.

I had my most recent physical exam last Thursday (occur every 6 weeks), and will have the next set of lab tests (also occur every 6 weeks) and the next CT scan before this month is out. So all is good.

My energy, stamina and mental concentration continue to improve weekly, but are still not back to normal yet. The neuropathy (nerve damage from the chemotherapy that resulted in numbness, tingling and weakness in my feet and legs) has improved tremendously but still is not back to normal. It has improved enough for me to realize that I have a corn on one foot and probably a Morton's neuroma (a painful nerve condition) on the other that were not bothering me as long as my feet were numb - so recovery is a mixed blessing! I am not getting back to normal as fast as I would like, and it is harder and harder to tell, when I nap on a weekend day, whether that is evidence of wisely "listening to my body" or evidence of just being lazy. Good to be at a point where I have to worry about the difference again...

How long can I expect to continue to have no evidence of disease? Impossible to tell. And believe me, I have tried to find medical literature that will predict it for all sorts of reasons. Most recently my air conditioning went out this weekend and I have to decide between a short term investment of replacing an engine and condensor or a long term investment of replacing the whole system.

One study predicts an average of 10.4 months before recurrence among stage III and IV patients who got standard chemo, extended nearly a year longer by Avastin (I am stage III, but Stage III C, so close to stage IV). Another predicts an additional 2 years on average of disease free survival added by the investigational dosing I got on this investigational trial. Overall the statistics say 20-40% 5 year survival and about 10% 10 year. And if you get 10 years out without evidence of recurrent disease, I am not sure what that means with ovarian cancer, but I think you can think in terms of possibly a cure. Who knows. I have good reason to be optimistic that my experience may be predicted by the more optimistic statistics, but no way to know for sure.

I think I am going to replace the whole AC system and assume I am investing for the long run.

Since there have been at least 2 instances of ovarian cancer and another 2 of breast cancer among our extended family and I know some of you have been worrying about what it means for your own risk or that of your daughters, I decided to get tested for the BRCA1 and BRCA2 genes (the genes recognized to be associated with hereditary risk for ovarian and breast cancer). The good news is that my tests were entirely normal with no mutation detected. Does that absolutely garantee that there is no increased genetic risk for breast or ovarian cancer in our family? Well, no. There is always a possibility that there is a rare genetic risk not recognized by these tests (and not yet identified by science). But it makes it unlikely.

And it is also possible that others of you may have one of these mutations, even though I do not. If you really want to know your own risk, then you (or your mother) needs to be tested. But this suggests to me that there is likely no clear genetic risk that came through the Walker side of the family, which is the side shared by 3 of the 4 cases mentioned above. So my disease does not likely have ominous implications for anyone else.

On another note, last week 3 women asked me who cut my hair. It made me laugh. But grateful that I again have enough hair for people to actually mistake my style as a fashion choice, I optimistically dropped by my stylist to inquire how much longer it needs to get before he can do some intentional shaping. He told me to come back in another month or so...

I think I am going to keep it short. It feels great in this really hot weather and is awfully easy to manage.

I keep hearing I need to post an update

So here it is. My blood pressure seems to be doing well - dialystolics (lower number) usually below 90 which is good and systolics (high number) staying in reasonable ranges as long as I remember to take my medicine.

the medicine itself sometimes has the side effect of making people feel really tired and sometimes even inducing clinical depression. I don't recognize an impact, but it would be hard to tell since I am tired all the time these days anyway but anything feels better than I did.

Strength and endurance continues to improve by the week. I am not doing a detail (have been loaned to another office for a temporary project) that has me working and concentrating all day. I can tell I am more tired at the end of the day, but I am managing close to normal productivity although I still try to keep my day to 8 hours and no longer. So that is all good.

Some days I feel almost normal. And other days I feel like this is the hardest part, with certainty about the future lending a sense of urgency to the desire to recover fully and complete every thing that matters as efficiently as possible. When it all gets overwhelming I retreat to the recliner and nap. Things are usually better when I wake up.

And the neuropathy continues to retreat. Some days i am hardly aware of it until I pay attention to the fact that I continue to walk more like Frankenstein than a ballerina. Still balance is less of a problem and the feet are feeling closer to normal. All is good.

Louisa

New Wrinkle

Thursday I had my 6 week stop for laboratory testing. Elizabeth, my excellent chemo nurse, noted that my Blood pressure was running high and asked if that had been a problem before. I had taken my BP regularly at the beginning of my chemo but had neglected to do so in recent months.

I was feeling pretty lousy Thursday and returned home to nap in the recliner and watch TV. So I was pretty relaxed when I decided maybe I should haul out my BP kit and take my BP again. Wow - never knew it could be that high. Repeated it several times thinking maybe I was doing something wrong, but it just kept being high and sometimes getting higher, including the next morning when I took it before getting out of bed, and again before departing for work.

So to make a long story short - yesterday I got to start medicine for hypertension. This is not so unusual I think - as this is a known complication of the Avastin. I am relieved that I get to take medication for the BP and keep taking the Avastin.

And I feel much better today. Interesting, as I always tell patients that high blood pressure does not make you feel bad, but it raises your risk of stroke and heart attack so it is important to treat it. But now I am wondering if my feeling lously all over, then better after starting the meds means that, at least some times, hypertension DOES make you feel bad as well as raising your risk of stroke and heart attacks.

You learn a lot by being a patient. Maybe I should take my BP again and see if feeling better corresponds to a lower BP...

Always something new and exciting.

Update July 10,2010

Just returned from 9 days in Cherokee NC practicing medicine at the Cherokee Indian Hospital Urgent Care Clinic. Can't say I was really able to pull my weight, but at least I pretended to. For example, one day in clinic I saw 5 patients - the other doc saw 15 in the same time period. But the Cherokee folks were very supportive as usual, I enjoyed the switch and it gave me a good opportunity to compare my current progress against a real benchmark. In Atlanta and at CDC after spending the last 2 month of chemo in a recliner chair just about anything I do feels like progress. In Cherokee the bench mark was what did I usually do when there.

First - I could not pick up my "clinical bag", a large canvas sack that stores all the things I need (or may need) when practicing clinical medicine but do not (or rarely) need at CDC. When I finish a clinical stint I wash my white coat and repack the bag so it will be ready for the next time. It is usually packed with things I use often (like little paperback references) or continually (like my stethoscope) but also with things I use rarely or only theoretically need (like a large book on trauma medicine). IT is always too heavy, and I also think I should lighten it up. But this time I had to remove the things I knew I would not be using this time around before I could pick it up.

Second - I found the hike up from the lower parking lot - which always leaves me thinking I need to work out more - was totally exhausting. I managed it but had to stop and rest several times. After the first couple of days I parked in the closer patient parking or permenent staff parking areas and avoided the hike.

Third - just sitting on a stool without a back is more energy demanding than sitting in a chair with a back. I never really noticed this before, but i was very aware of it this time.

Fourth - On Monday it was a holiday so the clinic was closed and I was an add on in the ED. I bowed out and went home after only about a 6 hour day feeling really exhausted. And despite my plans to capture some of the folks who were very supportive to me during chemo and take them to lunch after church on Sunday, without an alarm I failed to wake up until 11:45. So no church, no capturing, no treating folks to lunch or even seeing them. Well - next time.

Fifth - in addition to the physical stamina limits, It was very clear to me that as I get more tired, my ability to think clearly and precisely and efficiently also declined.

Still all in all it went relatively well. I was delighted to be back in Cherokee and Sylva for a short while. I really enjoyed being in the mountains. And it was good to have a more solid comparison to assess where I stand in terms of come back. And the increased physical demands left me thinking it is probably time to begin intentional exercise again - although likely limited to the end of the week so I don't wear out when I still need to make it to work the next morning.