Good News for Bispecific Mosunetuzumab

The maker of Mosunetuzumab, the bispecific, released news this week that their phase III clinical trial for Mosunetuzumab and Lenalidomide seems to be an improvement over R-Squared. I think I have received about 20 different notifications from Google Alerts about it. That's a decent indication that this is a big deal.

As you probably know, Mosunetuzumab is the first bispecific to be approved for treating Follicular Lymphoma. Bispecifics work because they have two parts. One targets a protein on the surface of the cancer cell (CD20) and the other targets a protein on an immune cell (CD3). By attaching to both, it brings the immune cell next to the cancer cell and allows the immune cell to eliminate it. 

The phase III clinical trial is called CELESTIMO. It's a two-arm randomized study, meaning the 400 or so patients in the trial are randomly given one of two treatments. So ne group received Mosunetuzumab + Lenalidomide, and the other received R-Squared (Rituxan + Lenalidomide, also known as Revlimid, which gives you the two Rs).

[I want to make a prediction here. Mosunetuzumab is also known as Lunsumio. This combination is going to end up being known as L-squared -- Lunsumio + Lenalidomide. If you're comparing it to R-Squared, this just seems inevitable. I'm all for it. I just wish this blogging program did a better job with superscripts so I wouldn't have to type out :Squared" all the time.]

The results of the CELESTIMO trial are very positive. The manufacturer says the Mosunetuzumab combination resulted in a higher PFS (Progression Free Survival) than the R-Squared, meaning it took longer for patients' disease to become get worse. The manufacturer also said there were no new side effects from combination, only those that were already known about from Mosunetuzumab and Lenalidomide separately.

The manufacturer didn't release any data to back all of this up. They said they will do that either at an upcoming medical conference or in a publication.

[Prediction #2: They'll release the results at ASH and it's going to be one of the major sessions, big enough to be held in the ballroom of the hotel. And then it will be published in the journal Blood just a few days later.]

It's a big deal, given R-Squared's history. The combination was approved in the U.S. in 2019, and it was seen as a major step forward. It was the first non-chemotherapy treatment that was shown to be as effective as traditional chemotherapy like R-CHOP or Bendamustine. Chemotherapy still has a place in FL treatment, but newer treatments are more targeted, doing less damage to healthy cells. (To be clear -- one big takeaway when R-Squared was approved was that it had different side effects than chemotherapy. Not better or worse, but different.)

So if a second non-chemotherapy treatment exists that better than both chemo and R-Squared, then that's a very big deal. We won't really know just how big a deal until the manufacturer releases the data that shows us how effective and how safe it really is.

It's also a big deal given all of the excitement that we saw over the summer from the EHA conference over a presentation on Epcoritamab and R-Squared. Epcoritamab is the second bispecific to be approved for FL, and it has been used in combination with several other treatments in different trials. I suspect the manufacturer of Mosunetuzumab released this news without any data because they wanted to remind people that Mosunetuzumab is still around and there is plenty to be excited about for their bispecific as well.

I'll keep an eye on this one. I'm pretty confident we'll get the data at ASH in a few months (though I'm also notoriously not good at predicting things.) 

More soon. I have to get a few more posts in while I can still use both arms. 

Seasonal Patterns of Cancer Diagnosis

Well, this post isn't about Follicular Lymphoma, but it's certainly about cancer. And not too complex. And with my bad shoulder, I'm trying to stay in the habit of writing, and "not too complex" is good for that. 

I saw an article this weekend called "Seasonal Patterns and Implications of Cancer Diagnosis Across Calendar Months," published in in JAMA Network Open. 

The objective of the research is pretty straightforward -- is there a month of the year that has more patients in the United States diagnosed with cancer than other months? And if so, why?

The answer is, yes, there is a month with more cancer diagnoses. It's January. This is, of course, the month when I was diagnosed.

The researchers looked at data from cancer registrations and found 30,184,124 cancer diagnoses between 2001 and 2019. (Hey, I was in there!)

They found that January was highest, with 8.81% of cancer diagnoses. Here's the full list:

January 8.81%

February 7.78%

March 8.51%

April 8.35%

May 8.44%

June 8.60%

July 8.17%

August 8.46%

September 7.98%

October 8.58%

November 7.85%

December 7.76% 

There isn't a huge difference between months, but enough to matter. There's a 1% difference between December and January, which is about 300,000 cancer diagnoses. And it's important to keep in mind that these numbers aren't about when people get cancer -- that is, when the disease begins -- but about when they are diagnosed -- when a doctor confirmed that they had it. That's important.

The other question is, why does this pattern exist?

The researchers can't say for sure, but a fairly simple explanation could be that there is lower clinical activity in December and higher in January because of the holidays. In the U.S., "the holidays" starts in late November with Thanksgiving and goes through January 1 with New Year's Day.  People are focused on parties, shopping, spending time with family. It's too happy a time to think about whatever symptoms might be showing up. 

It's also possible that "workforce and specialist availability" has an impact diagnostic timing. It's harder to get an appointment at some parts of the year. 

There are also insurance-related factors. In the U.S., we don't have a public insurance system like in Canada or the UK. It's a complicated system, where something like a "deductible" has an impact. That is, depending on the deductible level, a patient will have to pay for much of their care on their own before health insurance begins to pay. So diagnoses might come later in the year after a deductible level has been reached and some patients can finally afford it. 

And then there are things like awareness campaigns. October has a high number of diagnoses, partly because of an increase in breast cancer diagnoses. October, of course, is breast cancer awareness month. Summer sees a rise in some diagnoses of skin cancers like melanoma. Many people become more aware of skin cancer in the summer months, when they are wearing less clothing and spending more time in the sun.

For me, it seems like it was just coincidence, rather than some seasonal-related issue. I was dealing with health problems starting in June, and it was late November that I went to see a surgeon about the large lymph node near my hip. After some antibiotics didn't work, we scheduled a surgical biopsy, and the results didn't come through until January. I wasn't putting off my health because of the holidays. 

But I think the research makes an important point -- sometimes it's an outside factor that pushes us to take care of our health. It's an easy thing to put off, and I have had loved ones who waited too long to get a diagnosis because they were afraid of what they might find out. Their outcomes were not good, and I lost them much sooner than I wished.

So sometimes we should be the outside force. Not a holiday or an awareness campaign. Just a concerned individual who cares enough about someone to encourage them to see a doctor. 

I'll get back to the FL research soon. But this gives us some things to think about.  

 

 

 

 

I'm Kind of a Mess

I know it's been a week since I posted anything here. I've been dealing with some stuff.

I had an MRI this afternoon. Shoulder injury.

Last Thursday, after I finished my blog post, I went to a dog training class with my standard schnauzer. There was someone there with a 100 lb. German Shepherd, and the big dog really did not like my little dog. The big dog's owner commented on it a few times, how his dog really likes most dogs, but just doesn't like certain dogs, and mine seemed to be a one of them.

Which would be fine, except this dog owner also gets distracted easily, and at one point, his big dog broke away from him and ran at me and my little dog. (Don't worry! No dogs were harmed!). I moved to my left to put myself between the two dogs, but my dog moved to the right, pulling on the leash and twisting my arm. The big dog decided it didn't want any trouble after all and his owner eventually came and puled him away.

So I've been hurting for the last week or so. Everything is taking more time than I'd like it to. 

When I went to see the orthopedist a few days ago, he moved my arm around a lot, and had me try to move it on my own, and had me try to push against his arm in different ways, and mostly reacted to all of these things by saying, "Oh, that's not good." 

He suspects a bad tear of my rotator cuff, which is kind of what I figured, too (though I was hoping I'd lucky and it would just be a bad sprain).  I actually had a torn rotator cuff in my opposite shoulder about 12 years ago, so I know what to expect from here. Whether that's good or bad, I don't know. But there will be surgery, and weeks of recovery, and months of rehabilitation, if history is a guide. 

So, yeah, I'm kind of a mess. I'm looking back at the last year, and I'm not happy about it. I was in physical therapy for months because of a knee injury.  I hurt my back a few weeks ago and had to take a break from yoga. There's the whole MGUS thing. 

I remember reading a couple of years ago that our bodies go through large changes in our 40s and 60s. (I found the article! It's our mid-40s and early 60s.) So I'm ahead of the curve on both of those ages, with cancer at 40 and a bunch of other stuff before 60. My mom always told me I was very advanced, so there you have it. 

Before I finish, a little reflection on the MRI that I had today. It's been 12 years since I had one, and I really don't usually mind any kind of testing. I mean I don't look forward to the results, but I'm fine with scans or biopsies or shots or blood draws or whatever. But I was kind of anxious about this one for some reason. In the phone call to set up the appointment, and then in two online surgeries, I kept being asked about being claustrophobic. If you're not familiar with an MRI, you get fed into a small tube, so it's a very enclosed space. I remember 12 years ago being very squished in, so my injured shoulder had to be in an unnatural position, which was very painful, and I had to hold still for 30-45 minutes. It was not fun.

But this one was different. There was much more room in the tube -- I could lie flat -- and the whole process took less than 15 minutes. It was still awful, but not as bad as I had anticipated. 

I think about the advances in cancer treatment that have happened since then, too. It doesn't seem like it, but 12 years is a long time.  A whole lot has happened in the world of Follicular Lymphoma in that time.

As we were driving home, my wife said maybe there have been some shoulder surgery advances n that time, too, and I'll do some quicker healing. That would be wonderful. I will hold out hope.

Because hope is a good thing, maybe the best of things.  (Quoting Shawshank Redemption always makes me feel better.)

I'll keep you updated. And I'll try my best to get back to writing about Lymphoma research soon.

Take care.

 

 

Happy Lymphoma Awareness Month

If you're reading this blog, you're probably aware that this is Lymphoma Awareness Month. It's a good thing -- it's an opportunity for others to learn more about our disease. Lots of organizations are using the opportunity to do just that. If you follow the Follicular Lymphoma Foundation on social media, for example, you've seen their posts so far this month, highlighting symptoms in one, and questions that people have at diagnosis in another. Be sure to like them when you see them.They are good ways to have those posts show up on the feeds of your friends, followers, and connections. It's an easy way to spread awareness.

Almost every year, I make the comment that I really don't need an awareness month. I've been very aware of my Lymphoma for almost 19 years now. 

But it's a funny thing -- sometimes we're made aware of things whether we like it or not. 

Yesterday, I got a text and an email that there was a new letter in my Electronic Medical Records account. My first reaction was slight panic -- "Now what?" I asked myself.

I haven't had any appointments or tests or anything else in a couple of months.  What could one of my many healthcare providers need to tell me?

And what's up with it being a letter? I get the occasional message or result or note. But a letter? Is this 1857?

It turned to to be the very long set of notes from a genetic counselor that I spoke with a few weeks ago. I had put it out of my head.

If you aren't aware of this, a genetic counselor is a healthcare professional that provides advice about getting a genetic test to see if your DNA carries one or more genes that can cause certain cancers. The BACA gene is an example -- it can increase the risk of breast cancer. I have a family history of certain cancers that might have a genetic disposition. (Follicular Lymphoma is not one of them, as far as researchers know.)  If I choose, I can have a test that looks for those particular genes. And if it turns out that I have one, I can do things like be tested more earlier or more frequently, or in some cases, have surgery to remove non-vital organs that might be more prone to cancer.

As I said, I had the initial meeting with a counselor and then put it out of my head. I really don't know if I want to do it.

For one thing, I'm already so hyper aware of my own cancer history that I'm not sure it's necessary. I had a benign polyp on my last colonoscopy, so I'm getting tested in 7 years instead of 10. I see my oncologist twice a year. I see my skin doctor twice a year. I know every lump and bump on my body. I know when something doesn't feel right.

So it is the awareness worth it? I don't know.

Of course, the other reason to do this is because we pass on our genes to our children. Is it fair to them to not let them know if they carry a gene that increases risk? (There is never a guarantee that someone with a certain gene will get cancer.) Is it more fair to not tell them, so they don't have to live with the worry that I have experienced for 18 years, wondering if every lump and bum is cancerous? 

If I pass on my awareness, is that enough? Will they be vigilant enough to take care of themselves, knowing what I have been through?

I still don't know what I'll do about the genetic counseling. 

But I do know that awareness is a good thing. And it's worth celebrating the knowledge that there are tests available that can help us assess our risk. The questionnaire I filled out, and  the counselor, both asked if my relatives had been given genetic tests. Of course someone like my grandmother, who was born in 1907 and died in 1986, never had a genetic test. They weren't available.

And that's my point. We're living in a good time. Awareness is about hope. More knowledge might mean an earlier diagnosis and a life saved.

I hope you find something to celebrate this month. Treat yourself well. You deserve it.

 

Protecting the Heart During Chemotherapy

The JAMA Network Open published a research letter last week that I thought was very interesting. It's called "Primary Cardioprotection in Frontline Anthracycline Therapy for Adult Hematologic Cancers," and it brings up some important issues that get at the heart of where we are these days with Follicular Lymphoma treatments.

(There's a really funny pun in there that you'll get if you re-read this post.)

The research letter looks at some research on Anthracyclines, a class of traditional chemotherapy drugs.  They are very powerful. The "H" in "R-CHOP," a common chemotherapy for FL, stands for Hydroxydaunorubicin, which is also known as Doxorubicin or Adriamycin. This is the Anthracycline in the combination. It works by messing with the cancer cell's DNA so it can't grow and divide. 

But the big problem with traditional chemotherapy is that it can often do as much damage to healthy cells as it can to  cancer cells. And in the case of Anthracyclines, one of the places it can do damage is to the heart. This is why FL patients only get R-CHOP once, even if it was very effective. There is too much risk of heart damage over a certain dose, and it can take months or ears to show up.

The research here points out that there are ways to help minimize the heart damage that Anthracyclines can cause. First, patients can be given a drug called Dexrazoxane just before they receive the chemotherapy. This drug latches on to the byproducts of the Anthracycline to keep them from damaging heart cells. The other strategy is to use Liposomal Anthracycline Formulations. For this, the Anthracycline molecules are coated in lipids or fats that keep them from affecting heart tissue and lessening damage.

The researchers found that Anthracyclines are used in chemotherapy treatments for several different blood cancers, including FL. But these two strategies for cardioprotection (protecting the heart) are very rarely used.

They looked at medical records for blood cancer patients over 10 years (from 2014 to 2024) and identified patients who had received Anthracycline-based chemotherapy as a first treatment. They looked particualrl at patients who were diagnosed with Acute Myeloid Leukemia, Diffuse Large B-Cell  Lymphoma, Mantle Cell Lymphoma, and Follicular Lymphoma. They decided to focus their analysis to AML and DLBLC, because there were so few cases of cardioprotection for the MCL and FL patients.

(That's a huge problem that we'll get back to in a second.)

They looked at a total of 13,331 patients, including 3661 with AML, 7241 with DLBCL, 1154 with MCL, and 1275 with FL. There was "infrequent" use of cardioprotection -- only 2.4% of patients with AML and 1.1% of patients with DLBCL received either Liposomal Formulations or Dexrazoxane. As I said, the number of patients with FL who received cardioprotecion was too low to include (obviously, less that 1%).

The researchers are calling for more research into the use of cardioprotective strategies for blood cancer patients who receive Anthracycline-based chemotherapy, hopefully leading to greater use if the research justifies it.

I think there are a couple of important points that this brings up for us as FL patients.

First, this strikes me as a survivorship issue. As I have said many times, the idea of survivorship is becoming more and more important to me -- the idea that there isn't enough attention paid to what happens to patients after the treatment is over and we are told we are OK. I think "side effects" are often studied most intently for a fairly short period right after treatment. It's hard to measure long-term side effects. There are so many other reasons that an FL patient might have heart issues 10 years after treatment. But if Anthracycline-related issues might not show up for years, that doesn't mean there isn't a risk. I am fully in favor of research that tests out strategies for cardioprotection.

This is also an excellent reminder that side effects (long- and short-term) should get a thorough discussion when it comes time to decide on a treatment.As I have said before, even when I'm having a good visit with normal blood test results, I still like to bring up treatment possibilities. I'd rather have those conversations before they become necessary, rather than when I'm in a panic about choosing a treatment that needs to happen soon. It's a lot easier to have a thorough conversation then.

And this specific conversation matters. If you've been reading for a few months, you probably remember the research from last March on 15-year follow-ups of R-CHOP patients, and the possibility that R-CHOP had cured many of them.  I have no idea how this has been accepted by oncologists in the last 6 months -- if they are recommending R-CHOP to more patients. But if that's the case, then we need to do much better than 1% of FL patients receiving cardioprotection. This needs to be a part of the conversation if R-CHOP is back on the scene.

One other important point to remember -- no cancer treatment is without side effects. When R-squared was first declared an alternative to traditional chemotherapy, researchers were very clear that R-squared had side effects, and they weren't better than those from chemo, they were different. It's just not possible to fight something like cancer without causing other issues. The question is, how are those issues dealt with? What can researchers learn from some patients to better protect other patients? 

As I said, I think this kind of gets at the heart of where we are with FL treatments. There is, unfortunately, no single best way to treat FL. For all of the excitement about CAR-T and bispecifics and other immunotherapies, traditional chemo still has a place in FL treatment. And there's still lots to know. 

Do your best to keep up -- enough to be able to have a good conversation with your doctor when the time comes.

 

R-Squared: A Systematic Review

The Blood Cancer Journal just published an article called "Lenalidomide and Rituximab for Relapsed/Refractory Follicular Lymphoma: A Systematic Review and Meta-Analysis." 

We're at a point now where R-squared (Lenalidomide/Revlimid + Rituxan) is pretty firmly a part of our lives as Follicular Lymphoma patients. It's a standard treatment, the first option approved that showed to be as effective as traditional chemotherapy (but with a different set of side effects). It has been with us for about 7 years now as an approved treatment.

So this article is a "systemic review" of what we know about R-squared. It looks at all of the research that has been done since 2015, when the first stage 2 clinical trial results were published, on R-squared in Relapsed/Refractory FL. The aim here is to see if all of the results show the same thing, especially when compared to the AUGMENT trial that led to the approval. 

The authors wanted to look at as wide a pool as possible, so in addition to looking at just R-squared, they also looked at Lenalidomide + Obinutuzumab, which like Rituxan is an anti-CD20 monoclonal antibody. They also looked at triplets -- R-squared + some other lymphoma treatment. Finally, they looked at not just published research, but also at research that was presented at ASH, the largest hematology conference in the U.S., and EHA, the largest conference in Europe. 

Looking at so many sources of data is great, in that it gives them much more to work with. But it also complicates things. Each study had its own criteria for inclusion, so the patients across the studies don't match up with each other exactly. Some studies, especially those from the conferences, did not include all of the data that the published studies did. And some studies used slightly different dosing, so patients didn't get the same amount of the treatment across all of the studies.

All that said, they were able to do some analysis that made it possible to compare the different studies.

The results of their analysis aren't surprising -- R-squared works.

The Overall Response Rate for all of the R-squared or Lenalidomide + Obinutuzumab studies was 75.9%, and the Complete Response Rate was 39.6%. For studies involving a triplet (R-squared + another lymphoma treatment), the ORR was 85.1% and the CRR was 53.9%. This makes sense -- a third treatment will, in theory, add another way for the cancer cells to be treated. But something else happened, too, that also makes sense -- the rates of serious side effects went up, too.

In case you are curious about what the third treatment was in those triplets, they were Idelalisib; Polatuzumab; Atezolizumab; Bendamustine; ViPOR [a combination of 5 treatments, not three -- Venetoclax, Ibrutinib, Prednisone, Obinutuzumab, and Revlimid]; Tazemetostat; Acalabrutinib; Epcoritamab; Azacitidine; and Tafasitamab. Some of those names are probably familiar to you, and I have written about a bunch of these trials over the years. You can search for them at the top of the page.

The analysis also broke down the data in a few other ways, including prior lines of therapy. They wanted to see if R-squared was more or less effective if someone had already tried a number of other treatments. If a treatment works when others don't, that's an important piece of data.  In studies where patients had received a median of just one prior treatment, the ORR was 76.7% and the CRR was 41.9%. For patients who had received a median of two or more prior treatments, the ORR was 73.5% and the CRR was 40.5%. There was no significant difference between the two -- R-squared works well no matter how many prior treatments a patient had received. The same was true for the triplets.

As for safety, as mentioned above, there were greater numbers of serious side effects for the triplets. Serious low white blood cell counts occurred in 46.6% of triplet patients, and just 29.1% of R-squared patients. There was a trend toward serious respiratory infections in the triplet patients vs. the R=Squared patients. Low platelet counts were similar in the two groups. Patients who had to leave the study because of serious side effects were also similar -- 23.3% in the triplet group and 16.6% on the R-squared group. 

There are other data breakdowns that you can read about in the article. Click the link. 

Overall, the analysis shows the effectiveness of R-squared and begins to look at some of the effectiveness of triplets, though they are generally more recent and will need more time to see long-term results. If you've been reading for a while, you now I like those "Here's where we are" articles and videos where an expert gives us an update on things that have happened in the past. I see this as one of those articles. It's clear the R-squared is effective and safe for Refractory and Relapsed patients and provides and important option for those of us in that situation. 

Photographs and Memories

I have an old phone. It doesn't have a huge amount of storage on it, so it fills up fast, to the point where I can't do any updates because there isn't any space.

I know the reason. I run my dog's Instagram page (oh yes -- that guy named Lympho Bob is not my only online persona).  I take several pictures of the dog every day. "For online content," I say to my wife and kids who roll their eyes at me when I tell them to keep still so the dog will stay in whatever cute position she is in. I end up with way more photos and videos on my phone than I actually need. And then I forget to go back and erase them and they pile up.

So over the last few weeks, I've been going through the photos on my phone, erasing anything that I don't really need, like duplicate photos of the dog or old memes that I though were funny and may r may not think the same now. Last week, my wife and youngest kid and I took a train ride into New York City to go to the Metropolitan Museum of Art. It's an amazing place. I spent the 2 hour train ride going through all of my photos for 2023. I had a ridiculous number of photos of my dog sleeping while she's lying on her back. Maybe two of them ended up on Instagram. It was very therapeutic to erase so many of them and create some space.

As you might imagine, going through thousands of photos brings back some memories. And some of those memories are directly related to being a cancer patient.

I found several photos that I had saved over several months, all variations of the same meme: "My Lymph Nodes are Assholes." I liked that one a lot, enough to save it whenever it came up. I don't think I ever re-posted it anywhere, including in this blog. But I enjoyed the fact that it kept coming back to me, and I kept enjoying it. And it's true -- if my Lymph Nodes were people, I probably wouldn't want to spend much time with them. They're much too negative. I'm getting to an age where I'm more selective about who I spend time with. I'd rather not have what they are offering.

I found another meme, a list written by a cervical cancer patient: "You Know You Have Cancer If...." and then there were 10 items like "You can pronounce difficult drug names correctly" and "You speak very freely about your own body." They were all very true. But my favorite was "You have a favorite vein." Because I do have a favorite vein -- left arm, along the inside of the elbow. It's a beautiful one -- I have been told so by many phlebotomists. In fact, when I get blood taken and the phlebotomist doesn't comment on how nice it is, I get a little insulted. "Pretty privilege," I think it's called. Those of us with beautiful veins can get a little bit obnoxious about it. 

I found a bunch of vacation photos of people I have met who are cancer survivors. My wife and I are doing our best to travel now, when we can, when we are healthy enough to enjoy it. We don't want to look back 10 years from now, wishing we had taken the trips we used to dream about. We're living the dreams now, as much as we can.

There were some photos of a group we had met on a river cruise, and one of the women in the group was a two-time breast cancer survivor. One night, when the wine was flowing at dinner, we started talking about how ridiculous it was to be diagnosed with cancer at a relatively young age -- me at 40, she in her late 30s. We were laughing in a way that cancer patients do sometime. But it wasn't a happy conversation for her husband. He said to me, stone-faced, "But it wasn't funny when it happened, was it?" No, it wasn't. I told him about watching moving with my young kids and turning out the lights in the room so they wouldn't see me crying. 

It's funny how shared sadness can make someone feel happier. 

A few years before that, we traveled to Italy, something we'd talked about for 30 years. While we were there, we met someone who was in active treatment for lung cancer. She and her husband were great travel companions, and we spent a wonderful afternoon with them in Venice -- one of our favorite travel memories in many years of traveling. Of course, it came out that both of us were in different stages of our dealing with cancer. She was a cancer blogger and writing teacher, like me. We had lots to talk about.

I kept up with her blog for a long time. As I said, she was in active treatment when we met. She is a long-distance bike rider, and enjoyed good days when she could get out and ride. She hasn't written anything on her blog since April. It was good news at that point -- she was able to see her oncologist three times a year instead of four. So I'm going to assume she's doing well and spending her time riding instead of writing. Writing about cancer is hard to keep up sometimes, I know. We all need a break. 

We had corresponded by email for a while, and that made me think of all of the emails I have received over the years from readers. I think about you all a lot. It's true. I'll read or something that will make one of you pop into my head. The filmmaker from the Netherlands. The doctor who retired and moved to Portugal. The marathoner from Ireland. The second amendment advocate who was finding out information for her brother. The guy who just wanted to stop thinking about cancer and get back to riding his motorcycle with his wife. I am honored that you reached out to me and trusted me with your stories. I save all of those emails, and every now and then I think about writing to you to ask how you are doing. But I don't, because maybe you're in a place where you don't want to think about all of this anymore. And I respect that. 

But I'd also love to hear from you if you're still reading. I'd love to now that you're doing OK. 

Cancer is such a long, strange trip if we're lucky. I hope all of you are able to make happy memories and have some time to reflect on them. And maybe smile a little.