Just a reminder that the endorsement/voting period for the WEGO Health
Awards is over in just a few days. I've been nominated for three awards:
Best in Show: Blog, Patient Leader Hero, and Lifetime Achievement.
If you are so inclined, you can click on the badges on the right side of the screen, or the badge below. Or you can click here to go to my nomination profile.
WEGO Health Awards are given each year to patient advocates. The
"endorsement" phase goes until this Friday, July 31. The top three vote-getters in
each category go to the finals. A panel of judges will pick three more finalists for each category. Then a different panel will choose the
winners.
Thanks, as always, for your support.
Tuesday, July 28, 2020
Friday, July 24, 2020
R-Squared in Untreated Follicular Lymphoma
More evidence that R-squared is a very good option for many Follicular Lymphoma patients.
R-squared, as you probably know, is the combination of Rituxan and Revlimid (also known as Lenalidomide). It was approved by the FDA in May 2019 for previously-treated FL patients. It was big deal -- it showed that it was possible for a non-chemotherapy treatment to be as effective and safe as traditional chemo. If you've been reading Lympho Bob for a while, you know I've been tracking it for a long time. For years, lymphoma specialists have been saying R-squared could be a game-changer.
So while it has been approved for previously-treated FL patients, there is now more evidence that it is effective for untreated Follicular Lymphoma patients, too.
A recent article in the journal Blood Advances, called "Lenalidomide/rituximab induces high molecular response in untreated Follicular Lymphoma: LYSA ancillary RELEVANCE study," makes this clear.
The research describes a smaller part of the large clinical trial known as the RELEVANCE study (which I have written about a few times). This trial was a comparison of R-squared and Rituxan + chemo, in FL patients that had not yet had treatment. Half the patients were given R-squared, and half were given R + chemo.
A smaller group within the RELEVANCE trial were part of an MRD study. MRD stands for "Minimal Residual Disease." It's the idea that something like a CT scan won't see the smallest little bits of cancer that might remain in a patient's body after treatment. Looking more closely at DNA samples will show if all of the cancer is really gone, more that what a scan might show.
So in the research described in the article, 222 with a particular genetic issue (a BIOMED-2–detectable BCL2-JH translocation) were analyzed. In other words, these patients had a specific problem with their DNA that caused the Follicular Lymphoma. That's important -- successful treatment would mean that the cells with that DNA problem would be wiped out. If a blood test or bone marrow test showed some of those cells were still around, then the treatment didn't result in a true Complete Response. If it did, it resulted in what's called a Complete Metabolic Response, or CMR -- no messed up DNA in any of the cell samples they took.
These 222 patients were given the treatments in the study (117 were given R-squared and 90 were given R + chemo -- that doesn't add up to 222 but that's either because some patients didn't complete the study or I'm just really n\bad at math).
Complete Metablic Response at 24 weeks was achieved in 105 of the 117 R-Squared patients (90%), and in 70 of 90 R + chemo patients (77%). That's a great thing for R-Squared.
Just as importantly, the patients who had a CMR at 24 weeks were more likely to have a long-lasting response to the treatment, whichever treatment they had. Patients with a CMR had a 3 year Progression Free Survival of 84%, while those who didn't have a CMR (they still had some cells with the messed up DNA after 24 weeks) had a PFS of just 55%.
So two important results: more evidence that R-Squared is effective in Follicular Lymphoma patients who had it as their first treatment, but also, more evidence that CMR is a good predictor of how long a treatment will last. Knowing that a CMR wasn't achieved might mean that Maintenance might be a good idea, or that a salvage therapy (a new treatment right after a partially successful treatment) might be necessary.
Overall, some good news for those who are considering R-Squared, but also good news for all of us that want to know how well a treatment might have worked.
R-squared, as you probably know, is the combination of Rituxan and Revlimid (also known as Lenalidomide). It was approved by the FDA in May 2019 for previously-treated FL patients. It was big deal -- it showed that it was possible for a non-chemotherapy treatment to be as effective and safe as traditional chemo. If you've been reading Lympho Bob for a while, you know I've been tracking it for a long time. For years, lymphoma specialists have been saying R-squared could be a game-changer.
So while it has been approved for previously-treated FL patients, there is now more evidence that it is effective for untreated Follicular Lymphoma patients, too.
A recent article in the journal Blood Advances, called "Lenalidomide/rituximab induces high molecular response in untreated Follicular Lymphoma: LYSA ancillary RELEVANCE study," makes this clear.
The research describes a smaller part of the large clinical trial known as the RELEVANCE study (which I have written about a few times). This trial was a comparison of R-squared and Rituxan + chemo, in FL patients that had not yet had treatment. Half the patients were given R-squared, and half were given R + chemo.
A smaller group within the RELEVANCE trial were part of an MRD study. MRD stands for "Minimal Residual Disease." It's the idea that something like a CT scan won't see the smallest little bits of cancer that might remain in a patient's body after treatment. Looking more closely at DNA samples will show if all of the cancer is really gone, more that what a scan might show.
So in the research described in the article, 222 with a particular genetic issue (a BIOMED-2–detectable BCL2-JH translocation) were analyzed. In other words, these patients had a specific problem with their DNA that caused the Follicular Lymphoma. That's important -- successful treatment would mean that the cells with that DNA problem would be wiped out. If a blood test or bone marrow test showed some of those cells were still around, then the treatment didn't result in a true Complete Response. If it did, it resulted in what's called a Complete Metabolic Response, or CMR -- no messed up DNA in any of the cell samples they took.
These 222 patients were given the treatments in the study (117 were given R-squared and 90 were given R + chemo -- that doesn't add up to 222 but that's either because some patients didn't complete the study or I'm just really n\bad at math).
Complete Metablic Response at 24 weeks was achieved in 105 of the 117 R-Squared patients (90%), and in 70 of 90 R + chemo patients (77%). That's a great thing for R-Squared.
Just as importantly, the patients who had a CMR at 24 weeks were more likely to have a long-lasting response to the treatment, whichever treatment they had. Patients with a CMR had a 3 year Progression Free Survival of 84%, while those who didn't have a CMR (they still had some cells with the messed up DNA after 24 weeks) had a PFS of just 55%.
So two important results: more evidence that R-Squared is effective in Follicular Lymphoma patients who had it as their first treatment, but also, more evidence that CMR is a good predictor of how long a treatment will last. Knowing that a CMR wasn't achieved might mean that Maintenance might be a good idea, or that a salvage therapy (a new treatment right after a partially successful treatment) might be necessary.
Overall, some good news for those who are considering R-Squared, but also good news for all of us that want to know how well a treatment might have worked.
Saturday, July 18, 2020
New Information on FL Survival
The Blood Cancer Journal published a very new article on Follicular Lymphoma this week that has (in my opinion) some very important things to say about FL treatments and survival. It isn't all necessarily brand new information, but it confirms some important things, and has some big implications.
Before we get to the specifics, I want to point out that this article looks at a lot of statistics, and makes statements about how treatments and FLIPI scores affect Overall Survival. So here is your very important reminder: Statistics do not have any impact on you as an individual. Numbers are not destiny. A number that describes the median Overall Survival for a large group does not describe each person in that group. If the median Overall Survival of a group of cancer patients is 10 years, that doesn't mean that any individual in that group will die in 10 years. It means half of them lived less that 10 years, and half lived more than 10 years. And notice the past tense -- those numbers are based on things that happened in the past, and may not account for the effects of newer treatments.
Click here to learn more about (or remind yourself about) how to read FL survival statistics. The important thing to remember is a statistic about a large group is not a prediction about you as an individual.
***************************
On to the article.
It's called "Follicular lymphoma in the modern era: Survival, treatment outcomes, and identiļ¬cation of high-risk subgroups." The study looks back at patients who were treated for FL at Memorial Sloan Kettering Cancer Center in New York between 1998 and 2009. The researchers were interested in a few things -- what the Overall Survival was for the group; the OS after each new treatment; and how FLIPI scores might change over time, and the possible effects of that change.
So here's the first good bit of news -- in this group of 1088 FL patients (all were grade 1 to 3A), the median Overall Survival had not yet been reached. That's always good news. If median OS measures the point at which half of the patients have died, then the longer it takes to get to that point, the better. The researchers point out that there have been "more than 20 years follow-up" with the earliest patients in the study, and the median OS has still not been reached. As I said, that's a very good thing, and it's in line with a lot of what I have seen lately in trying to figure out an OS for FL.
One of the two main lessons the researchers learned from this study has to do with OS and PFS after each line of treatment. By this, they mean a new treatment after the last treatment has stopped working. So someone might get B-R as a first line treatment. After a few years, they need treatment again, and maybe R-squared is the second line treatment. Then maybe RadioImmunoTherapy a few years later as a third-line treatment. And so on.
As they point out, there hasn't been much research on the OS and PFS for different lines of treatments. We look at OS for the whole group, but not how well patients do after each line.
Here's what they found:
They looked at 1088 patients altogether. 164 of them (about 15%) never needed treatment.
922 (85%) had a first line treatment. Again, median OS was not yet reached for this group, and the PFS was 4.73 years.
475 (43%) had a second line treatment. Median OS for this group was 11.7 years, and PFS was 1.5 years.
299 (27%) had a third line treatment. Median OS for this group was 8.8 years, and PFS was 1.1 years.
198 (18%) had a fourth line treatment. OS was 5.3 years and PFS was 0.9 years.
128 (12%) had a fifth line treatment. OS was 3.1 years and PFS was 0.6 years.
81 (7%) had a sixth line treatment. OS was 1.9 years and PFS was 0.5 years.
It's easy to see that the more treatments a patient has, outcomes get worse. This makes sense -- a more aggressive form of Follicular Lymphoma will require more treatments. Again, I will remind you that numbers don't predict any individual's future. A 5.3 year OS after a fourth treatment means that half of those 198 patients lived longer than 5.3 years.
What I find really interesting about this group of statistics is the fact that fewer and fewer patients need more treatments. In other words, not all 922 patients needed 6 lines of treatment -- only 7% of them did. There are lots of reasons for that (including the age of "typical" FL patients). But for me, it was a nice reminder that what I learned when I was diagnosed wasn't right. I was told that FL gets more aggressive over time -- a first line treatment might last 8 years, then the second line might last 3 years, then 2 years, etc. That's certainly the case for some patients, but not all. (And certainly not for me.) In my mind, I would be dealing with treatments every few years. For a lot of patients, we get long periods between treatments. This data supports that. And I think it's an important reminder, especially for newly diagnosed patients.
Of course, that shorter OS and PFS from line to line is important to the researchers. Because OS is so hard to measure (since FL patients are living so much longer), then PFS between lines might be an important benchmark for treatments. In other words, when a new treatment is being considered for approval, maybe a good way to think about it would not be "Does this treatment increase OS?" but instead "Does this treatment increase the PFS for patients who have received a fourth line of treatment?" A treatment might help a large group in a certain way, but looking more closely at the statistics, we can find that it helps a smaller group in a more significant way.
****************************
The second big lesson from the study had to do with FLIPI scores. I'm setting this off in a new section because I want to make sure this is explained clearly.
I've written about FLIPI before. It's the Follicular Lymphoma International Prognostic Index. The idea behind it was to look at a few different factors (originally patient age, FL stage, LDH levels, hemoglobin levels, etc). Patients were categorized as low, intermediate, and high risk, with worsening survival rates for each.
FLIPI is problematic for lots of reasons, and there have been lots of attempts to make it better. The important thing here is, like with any FL statistics, a particular FLIPI score does not indicate anything about you as an individual. My own FLIPI made me "intermediate risk" at diagnosis, giving me a 10 year survival of 51%. That was 12 years ago. A group's numbers are not your own destiny. Remember that.
So back to the study.
The researchers looked at the patients who watched-and-waited after diagnosis. Many of them never needed treatment. Some did eventually. The question they asked was, what happened to patients whose FLIPI score changed during the time they were watching and waiting?
A little context for this one. Many patients are able to watch and wait after diagnosis (I was one of them). Instead of getting treatment right away, our FL was stable, or less aggressive. My own oncologist had the philosophy of doing as little as necessary, so he suggested watching and waiting. There is no difference in OS between patients who wait and those who get treatment right away (which this study confirmed).
For those watch-and-wait patients who do need treatment after a while, there is some kind of event that triggers the need. For me, it was swelling in my left leg, caused by lymph nodes that were blocking some things and causing swelling. Other patients might have other events that trigger the need for treatment. There's no objective event that makes a doctor say "It's time to start treatment." Some might be more willing to let the waiting continue, as long as there are no major problems.
This study essentially asks if a change in FLIPI score might be that kind of objective event. If a patient's hemoglobin dropped, or LDH level went up, maybe that's a signal that the FL is getting more aggressive and treatment is necessary.
And that's just what they found. Patients who had a change in FLIPI score had a PFS of about 3 years, while patients who had a stable FLIPI had a PFS of 6 years. Change in staging, number of nodes involved, and LDH were the FLIPI factors that were most important.
The researchers suggest that FLIPI might be used to identify patients who are watching and waiting that might need treatment sooner than a doctor's clinical observation would suggest. In other words, if my doctor had paid attention to my FLIPI, he might have suggested treatment sooner than he did by seeing the potential problems associated with my swollen leg. The researchers suggest that maybe watch and wait isn't as good an idea as it might once have been.
This lesson is interesting to me, given that I am a part of the group that it looked at (though not a part of the study). But it seems kind of obvious to me that certain events (like more nodes being involved, or an increase in LDH evels) would make an oncologist take notice and suggest treatment. I guess the suggestion that something more objective, like a FLIPI score change, should be the measure, is a good one. But I also hope that any doctor who thinks watching and waiting is a good idea is also the kind of doctor who would look carefully at changes in data, and make careful decisions based on those changes.
**************************
So, for me, there are some good things to come out of this, and some other things that are not exactly bad, but that do confirm some less positive things about FL that we already knew. (How's that for looking on the bright side?)
I do like that the long Overall Survival for FL has been confirmed. I like that the idea that everyone's FL will get more aggressive over time has been questioned. I like that watching and waiting works for lots of people.
The study also brings anew set of data to researchers who can think about how it changes their views of things. There is a nice section on how this study matches up with some other big studies of FL patients. More knowledge is good.
The researchers also are clear that this study has limitations. It was a look at only one cancer center, so there is a chance that geography plays a role. It is also retrospective, looking back at patient records from 20 years ago, so it doesn't account for newer developments, and doesn't let researchers ask the kinds of questions that might wanted to have asked. They can only use the data that is available.
Still, it's a good opportunity to remind ourselves that statistics can tell researchers a lot, but they can't tell us anything about ourselves as individual patients. Each of our situations will be different. The best we can do is learn as much as we can, and work with an oncologist that we trust to get the best care for ourselves that we can.
Before we get to the specifics, I want to point out that this article looks at a lot of statistics, and makes statements about how treatments and FLIPI scores affect Overall Survival. So here is your very important reminder: Statistics do not have any impact on you as an individual. Numbers are not destiny. A number that describes the median Overall Survival for a large group does not describe each person in that group. If the median Overall Survival of a group of cancer patients is 10 years, that doesn't mean that any individual in that group will die in 10 years. It means half of them lived less that 10 years, and half lived more than 10 years. And notice the past tense -- those numbers are based on things that happened in the past, and may not account for the effects of newer treatments.
Click here to learn more about (or remind yourself about) how to read FL survival statistics. The important thing to remember is a statistic about a large group is not a prediction about you as an individual.
***************************
On to the article.
It's called "Follicular lymphoma in the modern era: Survival, treatment outcomes, and identiļ¬cation of high-risk subgroups." The study looks back at patients who were treated for FL at Memorial Sloan Kettering Cancer Center in New York between 1998 and 2009. The researchers were interested in a few things -- what the Overall Survival was for the group; the OS after each new treatment; and how FLIPI scores might change over time, and the possible effects of that change.
So here's the first good bit of news -- in this group of 1088 FL patients (all were grade 1 to 3A), the median Overall Survival had not yet been reached. That's always good news. If median OS measures the point at which half of the patients have died, then the longer it takes to get to that point, the better. The researchers point out that there have been "more than 20 years follow-up" with the earliest patients in the study, and the median OS has still not been reached. As I said, that's a very good thing, and it's in line with a lot of what I have seen lately in trying to figure out an OS for FL.
One of the two main lessons the researchers learned from this study has to do with OS and PFS after each line of treatment. By this, they mean a new treatment after the last treatment has stopped working. So someone might get B-R as a first line treatment. After a few years, they need treatment again, and maybe R-squared is the second line treatment. Then maybe RadioImmunoTherapy a few years later as a third-line treatment. And so on.
As they point out, there hasn't been much research on the OS and PFS for different lines of treatments. We look at OS for the whole group, but not how well patients do after each line.
Here's what they found:
They looked at 1088 patients altogether. 164 of them (about 15%) never needed treatment.
922 (85%) had a first line treatment. Again, median OS was not yet reached for this group, and the PFS was 4.73 years.
475 (43%) had a second line treatment. Median OS for this group was 11.7 years, and PFS was 1.5 years.
299 (27%) had a third line treatment. Median OS for this group was 8.8 years, and PFS was 1.1 years.
198 (18%) had a fourth line treatment. OS was 5.3 years and PFS was 0.9 years.
128 (12%) had a fifth line treatment. OS was 3.1 years and PFS was 0.6 years.
81 (7%) had a sixth line treatment. OS was 1.9 years and PFS was 0.5 years.
It's easy to see that the more treatments a patient has, outcomes get worse. This makes sense -- a more aggressive form of Follicular Lymphoma will require more treatments. Again, I will remind you that numbers don't predict any individual's future. A 5.3 year OS after a fourth treatment means that half of those 198 patients lived longer than 5.3 years.
What I find really interesting about this group of statistics is the fact that fewer and fewer patients need more treatments. In other words, not all 922 patients needed 6 lines of treatment -- only 7% of them did. There are lots of reasons for that (including the age of "typical" FL patients). But for me, it was a nice reminder that what I learned when I was diagnosed wasn't right. I was told that FL gets more aggressive over time -- a first line treatment might last 8 years, then the second line might last 3 years, then 2 years, etc. That's certainly the case for some patients, but not all. (And certainly not for me.) In my mind, I would be dealing with treatments every few years. For a lot of patients, we get long periods between treatments. This data supports that. And I think it's an important reminder, especially for newly diagnosed patients.
Of course, that shorter OS and PFS from line to line is important to the researchers. Because OS is so hard to measure (since FL patients are living so much longer), then PFS between lines might be an important benchmark for treatments. In other words, when a new treatment is being considered for approval, maybe a good way to think about it would not be "Does this treatment increase OS?" but instead "Does this treatment increase the PFS for patients who have received a fourth line of treatment?" A treatment might help a large group in a certain way, but looking more closely at the statistics, we can find that it helps a smaller group in a more significant way.
****************************
The second big lesson from the study had to do with FLIPI scores. I'm setting this off in a new section because I want to make sure this is explained clearly.
I've written about FLIPI before. It's the Follicular Lymphoma International Prognostic Index. The idea behind it was to look at a few different factors (originally patient age, FL stage, LDH levels, hemoglobin levels, etc). Patients were categorized as low, intermediate, and high risk, with worsening survival rates for each.
FLIPI is problematic for lots of reasons, and there have been lots of attempts to make it better. The important thing here is, like with any FL statistics, a particular FLIPI score does not indicate anything about you as an individual. My own FLIPI made me "intermediate risk" at diagnosis, giving me a 10 year survival of 51%. That was 12 years ago. A group's numbers are not your own destiny. Remember that.
So back to the study.
The researchers looked at the patients who watched-and-waited after diagnosis. Many of them never needed treatment. Some did eventually. The question they asked was, what happened to patients whose FLIPI score changed during the time they were watching and waiting?
A little context for this one. Many patients are able to watch and wait after diagnosis (I was one of them). Instead of getting treatment right away, our FL was stable, or less aggressive. My own oncologist had the philosophy of doing as little as necessary, so he suggested watching and waiting. There is no difference in OS between patients who wait and those who get treatment right away (which this study confirmed).
For those watch-and-wait patients who do need treatment after a while, there is some kind of event that triggers the need. For me, it was swelling in my left leg, caused by lymph nodes that were blocking some things and causing swelling. Other patients might have other events that trigger the need for treatment. There's no objective event that makes a doctor say "It's time to start treatment." Some might be more willing to let the waiting continue, as long as there are no major problems.
This study essentially asks if a change in FLIPI score might be that kind of objective event. If a patient's hemoglobin dropped, or LDH level went up, maybe that's a signal that the FL is getting more aggressive and treatment is necessary.
And that's just what they found. Patients who had a change in FLIPI score had a PFS of about 3 years, while patients who had a stable FLIPI had a PFS of 6 years. Change in staging, number of nodes involved, and LDH were the FLIPI factors that were most important.
The researchers suggest that FLIPI might be used to identify patients who are watching and waiting that might need treatment sooner than a doctor's clinical observation would suggest. In other words, if my doctor had paid attention to my FLIPI, he might have suggested treatment sooner than he did by seeing the potential problems associated with my swollen leg. The researchers suggest that maybe watch and wait isn't as good an idea as it might once have been.
This lesson is interesting to me, given that I am a part of the group that it looked at (though not a part of the study). But it seems kind of obvious to me that certain events (like more nodes being involved, or an increase in LDH evels) would make an oncologist take notice and suggest treatment. I guess the suggestion that something more objective, like a FLIPI score change, should be the measure, is a good one. But I also hope that any doctor who thinks watching and waiting is a good idea is also the kind of doctor who would look carefully at changes in data, and make careful decisions based on those changes.
**************************
So, for me, there are some good things to come out of this, and some other things that are not exactly bad, but that do confirm some less positive things about FL that we already knew. (How's that for looking on the bright side?)
I do like that the long Overall Survival for FL has been confirmed. I like that the idea that everyone's FL will get more aggressive over time has been questioned. I like that watching and waiting works for lots of people.
The study also brings anew set of data to researchers who can think about how it changes their views of things. There is a nice section on how this study matches up with some other big studies of FL patients. More knowledge is good.
The researchers also are clear that this study has limitations. It was a look at only one cancer center, so there is a chance that geography plays a role. It is also retrospective, looking back at patient records from 20 years ago, so it doesn't account for newer developments, and doesn't let researchers ask the kinds of questions that might wanted to have asked. They can only use the data that is available.
Still, it's a good opportunity to remind ourselves that statistics can tell researchers a lot, but they can't tell us anything about ourselves as individual patients. Each of our situations will be different. The best we can do is learn as much as we can, and work with an oncologist that we trust to get the best care for ourselves that we can.
Tuesday, July 14, 2020
Cancer Research and Covid-19
OK, I'll be up front about this from the start -- I'm going to ask you for a donation for cancer research. Keep reading, even if you're not able to contribute.
My friend Rodrigo wrote a few weeks ago asking of I thought all of the research being done on Covid-19 would mean less money for cancer research, especially research on Follicular Lymphoma. I said that I didn't think so, and I still think that's true. Much of the research on cancer has been going on for years. It can take up to 10 years for a treatment to begin in a laboratory, be tested on non-humans (like mice), and then go through phase 1, 2, and 3 clinical trials, before it can be approved by the FDA or another regulatory body. Often, that research is funded for multiple years at a time. Funders know a new treatment will take some time.
This idea seems to be on many minds. An article in CURE, a magazine for cancer patients, points out that the FDA is continuing to review and approve cancer treatments, despite the pandemic. And some of those treatments have been for Follicular Lymphoma, as you may know.
One problem, though, might come not so much from money being moved to different priorities, but instead from the working conditions that the pandemic has brought on. Many people have been working from home, me included. My work is conveniently something that I can do from home, fairly effectively. But that's not the case for someone who works in a state-of-art laboratory, working closely with a team of 8 or 10 people. Like, unfortunately, many cancer researchers. In fact, the American Cancer Society surveyed some cancer researchers, and found that about half of them had their research put on hold. This was mostly because they couldn't get to their labs. The ACS decided to delay their funding for two months -- researchers would normally get grant money in July, but will now get it in September.
But that's not to say money isn't a problem, too.
There might very well be some funds that are going to Covid-related research that might have gone to cancer research. More importantly, groups that raise money for cancer research are just going to have a tougher time. People have less money to donate, and events that used to get people excited about donating just aren't happening, or aren't happening in the same way. Cancer walks and benefit concerts are a lot tougher for people.
One of those events is the Pan Mass Challenge, a bike ride across Massachusetts that raises money for cancer research. My brother has raised thousands of dollars for this cause. that's the donation I mentioned above. More on that below.
So I don't think cancer research is going to stop, and as labs open up again, we might find that it is only behind by a few months. Maybe that doesn't matter in a few years, since research seems to be picking up speed, anyway. Or maybe being out of the lab gives researchers a chance to think creatively, and the change of scenery will result in new directions that might not have been considered before.
But we probably won't know the impact of Covid-19 on cancer research for a few years. My guess is, still, that in the long run, we're going to be OK.
*********************************
Now, on to fundraising.
The Pan Mass Challenge is a fundraiser for the Dana-Farber Cancer Institute in Boston, Massachusetts (where I grew up). Every year, thousands of people ride their bikes across the state, raising money and awareness.
One of those riders, for the 13th year, has been my brother Mike. In his time with the PMC, he has raised over $70,000 for cancer research, and I am very proud of all the work he has done. On his fundraising page, he explains why he rides:
I ride in memory of and support for my many family members and friends that have been cancer patients. I've seen the dedicated staff in action and outstanding care that patients have received at Dana-Farber, as well as the advances in treatment that are a direct result of the research conducted by the staff at Dana-Farber. Please help me by continuing to support the work of the Doctors at DFMC, and their quest to find a cure.
Because of the pandemic, those thousands of riders won't be able to ride together. Which is too bad -- less support from one another. However, they have found creative ways to continue the tradition, raise funds, and make sure that cancer researchers can continue their work. My brother will be part of a smaller group of riders who will do a 60 mile ride together through the towns that they live in. I admire their dedication.
Last year, riders raised about $63 million. This year, with less than three weeks to go before the ride, they have raised less than $18 million. They could use some help.
If you are able, please consider making a donation. My brother's fundraising page is here. Every little bit helps support cancer research.
Thanks for considering it.
My friend Rodrigo wrote a few weeks ago asking of I thought all of the research being done on Covid-19 would mean less money for cancer research, especially research on Follicular Lymphoma. I said that I didn't think so, and I still think that's true. Much of the research on cancer has been going on for years. It can take up to 10 years for a treatment to begin in a laboratory, be tested on non-humans (like mice), and then go through phase 1, 2, and 3 clinical trials, before it can be approved by the FDA or another regulatory body. Often, that research is funded for multiple years at a time. Funders know a new treatment will take some time.
This idea seems to be on many minds. An article in CURE, a magazine for cancer patients, points out that the FDA is continuing to review and approve cancer treatments, despite the pandemic. And some of those treatments have been for Follicular Lymphoma, as you may know.
One problem, though, might come not so much from money being moved to different priorities, but instead from the working conditions that the pandemic has brought on. Many people have been working from home, me included. My work is conveniently something that I can do from home, fairly effectively. But that's not the case for someone who works in a state-of-art laboratory, working closely with a team of 8 or 10 people. Like, unfortunately, many cancer researchers. In fact, the American Cancer Society surveyed some cancer researchers, and found that about half of them had their research put on hold. This was mostly because they couldn't get to their labs. The ACS decided to delay their funding for two months -- researchers would normally get grant money in July, but will now get it in September.
But that's not to say money isn't a problem, too.
There might very well be some funds that are going to Covid-related research that might have gone to cancer research. More importantly, groups that raise money for cancer research are just going to have a tougher time. People have less money to donate, and events that used to get people excited about donating just aren't happening, or aren't happening in the same way. Cancer walks and benefit concerts are a lot tougher for people.
One of those events is the Pan Mass Challenge, a bike ride across Massachusetts that raises money for cancer research. My brother has raised thousands of dollars for this cause. that's the donation I mentioned above. More on that below.
So I don't think cancer research is going to stop, and as labs open up again, we might find that it is only behind by a few months. Maybe that doesn't matter in a few years, since research seems to be picking up speed, anyway. Or maybe being out of the lab gives researchers a chance to think creatively, and the change of scenery will result in new directions that might not have been considered before.
But we probably won't know the impact of Covid-19 on cancer research for a few years. My guess is, still, that in the long run, we're going to be OK.
*********************************
Now, on to fundraising.
The Pan Mass Challenge is a fundraiser for the Dana-Farber Cancer Institute in Boston, Massachusetts (where I grew up). Every year, thousands of people ride their bikes across the state, raising money and awareness.
One of those riders, for the 13th year, has been my brother Mike. In his time with the PMC, he has raised over $70,000 for cancer research, and I am very proud of all the work he has done. On his fundraising page, he explains why he rides:
I ride in memory of and support for my many family members and friends that have been cancer patients. I've seen the dedicated staff in action and outstanding care that patients have received at Dana-Farber, as well as the advances in treatment that are a direct result of the research conducted by the staff at Dana-Farber. Please help me by continuing to support the work of the Doctors at DFMC, and their quest to find a cure.
Because of the pandemic, those thousands of riders won't be able to ride together. Which is too bad -- less support from one another. However, they have found creative ways to continue the tradition, raise funds, and make sure that cancer researchers can continue their work. My brother will be part of a smaller group of riders who will do a 60 mile ride together through the towns that they live in. I admire their dedication.
Last year, riders raised about $63 million. This year, with less than three weeks to go before the ride, they have raised less than $18 million. They could use some help.
If you are able, please consider making a donation. My brother's fundraising page is here. Every little bit helps support cancer research.
Thanks for considering it.
Friday, July 10, 2020
When Trials Don't Work Out
I've been thinking a lot about a comment that an anonymous reader made on my last post. The post looked at some history of Follicular Lymphoma, and the comment pointed out that Rituxan by itself had decent results (and I am one of those positive results, as you probably know). But over time, Rituxan was found to be a superstar because it was used in combination with other treatments, and made those treatments better.
So the comment provided a reminder that I very much appreciate: a single-agent treatment that does just OK by itself may have a great life afterwards. Combinations of treatments are often much more effective, and most newer treatments that are working their way up the clinical trial ladder are being tested in a bunch of different combinations to figure out the best way to use them.
Lenalidomide is a good example. It does OK for FL by itself, but combined with Rituxan to create R-Squared, and its results are about as good as chemo + Rituxan.
But there are lots of combinations that are tried that we never hear about. They might make it to a phase 2 trial, and then the results show that it's not as effective as current treatments, or maybe the side effects are too much (which can be a danger with combinations, since two or three treatments could potentially mean two or three times the side effects, though that doesn't always happen).
And there's really no incentive for the people running a trial to publicize the results of a failed trial. They don't need the negative publicity, after all. And the logic is that a failed trial isn't really going to help patients, so there's no point in making the results known.
But is that really the case? There might be something to be learned from failed trials. As a patient, I want to know what kinds of side effects, for example, are happening with some combinations. I like the Big Picture. I've kind of made a career out of cleaning up messes -- my own and other people's -- so I appreciate it when people are honest about failures.
And that's why I liked this article published about a month ago in Clinical Cancer Research: "A 3-Arm Randomized Phase II Study of Bendamustine/Rituximab with Bortezomib Induction or Lenalidomide Continuation in Untreated Follicular Lymphoma: ECOG-ACRIN E2408."
The study looked at Follicular Lymphoma patients who were getting their first treatment (Bendamustine + Rituxan), and then put into three groups: one received Rituxan Maintenance, the second got Bortezomib (Velcade) and then Rituximab Maintenance, and the third got Lenalidomide and then Rituxan Maintenance.
Results were just OK. The gal was to improve on BR + Maintenance, and adding either Velcade or Lenalidomide didn't significantly improve effectiveness, or reduce side effects (not surprising, when a new treatment is added). I have only seen the abstract, so I can't comment on details of the safety, but the closing of the abstract is pretty clear: "Conclusions: Altogether, neither bortezomib added to BR induction nor lenalidomide added to rituximab maintenance immediately post-BR induction are recommended in untreated FL."
As I said, I appreciate researchers being willing to talk about failure. They can certainly learn a lot, and perhaps we as patients can learn something, too. One of the questions we will all have to ask at some point is how much we are willing to balance effectiveness and safety. Are we willing to get more months or years between treatments if it means a loss of Quality of Life? How much? In what ways?
To me, even reading about failures brings up those questions, and helps prepare me for the choices I'll need to make some day, even if they won't involve these particular combinations. That's a good thing.
So the comment provided a reminder that I very much appreciate: a single-agent treatment that does just OK by itself may have a great life afterwards. Combinations of treatments are often much more effective, and most newer treatments that are working their way up the clinical trial ladder are being tested in a bunch of different combinations to figure out the best way to use them.
Lenalidomide is a good example. It does OK for FL by itself, but combined with Rituxan to create R-Squared, and its results are about as good as chemo + Rituxan.
But there are lots of combinations that are tried that we never hear about. They might make it to a phase 2 trial, and then the results show that it's not as effective as current treatments, or maybe the side effects are too much (which can be a danger with combinations, since two or three treatments could potentially mean two or three times the side effects, though that doesn't always happen).
And there's really no incentive for the people running a trial to publicize the results of a failed trial. They don't need the negative publicity, after all. And the logic is that a failed trial isn't really going to help patients, so there's no point in making the results known.
But is that really the case? There might be something to be learned from failed trials. As a patient, I want to know what kinds of side effects, for example, are happening with some combinations. I like the Big Picture. I've kind of made a career out of cleaning up messes -- my own and other people's -- so I appreciate it when people are honest about failures.
And that's why I liked this article published about a month ago in Clinical Cancer Research: "A 3-Arm Randomized Phase II Study of Bendamustine/Rituximab with Bortezomib Induction or Lenalidomide Continuation in Untreated Follicular Lymphoma: ECOG-ACRIN E2408."
The study looked at Follicular Lymphoma patients who were getting their first treatment (Bendamustine + Rituxan), and then put into three groups: one received Rituxan Maintenance, the second got Bortezomib (Velcade) and then Rituximab Maintenance, and the third got Lenalidomide and then Rituxan Maintenance.
Results were just OK. The gal was to improve on BR + Maintenance, and adding either Velcade or Lenalidomide didn't significantly improve effectiveness, or reduce side effects (not surprising, when a new treatment is added). I have only seen the abstract, so I can't comment on details of the safety, but the closing of the abstract is pretty clear: "Conclusions: Altogether, neither bortezomib added to BR induction nor lenalidomide added to rituximab maintenance immediately post-BR induction are recommended in untreated FL."
As I said, I appreciate researchers being willing to talk about failure. They can certainly learn a lot, and perhaps we as patients can learn something, too. One of the questions we will all have to ask at some point is how much we are willing to balance effectiveness and safety. Are we willing to get more months or years between treatments if it means a loss of Quality of Life? How much? In what ways?
To me, even reading about failures brings up those questions, and helps prepare me for the choices I'll need to make some day, even if they won't involve these particular combinations. That's a good thing.
Monday, July 6, 2020
The History of Follicular Lymphoma
A lot of what I hear about Follicular Lymphoma comes from Google. I have a Google Alert set for "Follicular Lymphoma," so every morning, I get an email with links to the FL-related articles that have appeared online over a few days.
Many of them have to do with investing in companies that make treatments for Follicular Lymphoma. There are a lot them. I take that as good news -- if people are writing this much about how much money can be made on FL treatments, then things must be looking up for us, right?
Sometimes they are nice articles from local newspapers or TV channels with stories about people with Follicular Lymphoma who are holding fundraisers or running marathons. They are always inspiring. (Occasionally something I have written for another website comes up. I won't lie -- I think it's really cool every time it happens.)
And then there are the links to medical journal articles, or reports about them in sites for oncologists. These are also usually inspiring. It's mostly how I keep up on the latest and greatest news about Follicular Lymphoma.
Which is why it was so strange when an article from a medical journal from 2007 came up in my email. Most of what I get is very current -- posted online in the last day or two. But this one was 13 years old. My guess is that the journal just posted it, or re-posted it to a new site. But I read it anyway, even though it was 13 years old, based on the title:
"Follicular Lymphoma: A Historical Overview," published in the journal Leukemia and Lymphoma.
This was published a little less than a year before I was diagnosed. I was curious about what the state of the field was at that time. And I've read enough medical journal articles to know that there was probably going to be a section that said, basically, "Here is the history -- where we've been -- and now I'm going to tell you where we think the field should go." And that's the interesting part -- did the authors predict the direction things went?
(Spoiler -- they didn't, not exactly, and I don't think anyone could have predicted how FL treatments have developed.)
Here's some early FL history -- Follicular Lymphoma was first identified in 1925 by researchers in New York City. It was first named after them (Brill-Symmers Disease), and was considered benign. It was eventually discovered to be a type of lymphoma. This part is fascinating -- the first two patients with FL were 28 and 32 years old (much, much younger than the age most people are diagnosed with FL these days). They had radiation, and it gave them good results.
But here's the most important thing to come from the article -- Follicular Lymphoma was discovered in 1925. That means its 100th birthday is in five years. WE WILL HAVE A PARTY. You can be darn sure I will still be around in 5 years, and I expect all of you to be, too. I'm going to start planning soon. This Zoom stuff is nice, but I'm envisioning a big get-together, someplace nice, for anyone who can make it. Maybe a bunch of them, all around the world. Weird thing to celebrate, but it's 2020 and that's where we are these days.
There are some other fascinating bits, too (like, in a study of patients diagnosed between 1917 and 1939, 20% died within 2 years of diagnosis, which seems too much of a coincidence when we know today about EFS24 -- about 20% of patients will relapse within 2 years after immunochemotherapy. It was also considered very rare in the Western Hemisphere for the first part of the century, much like it is considered rare in Asia and Africa these days. That could be something environmental, or it could just be that it was hard to diagnose).
More interesting to me is the section on treatments. As I said, this was published a year before I was diagnosed, so it's fascinating to see what was available at that time. The article mentions radiation (mostly useful for stage 1 and 2 disease); Chemotherapy (especially CHOP, CVP, and Fludarabine, which were pretty much the options presented to me -- no Bendmustine at that time. Interestingly, Interferon is mentioned, something that never really caught on in the United States (though I know is still popular in Europe). Also, watching and waiting is discussed under chemo, since there were some studies that compared the two. Bone Marrow or Stem Cell Transplants are also discussed, especially Allo transplants, though the potential problems are also brought up. And then there are targeted therapies, especially Rituxan. Rituxan had only been approved for 10 years, so the article is hopeful that R + chemo would result in a long-term Overall Survival benefit. There is also some discussion of RadioImmunoTherapy, and of vaccines, and of anti-bcl treatments.
All of this brings back memories for me, especially the excitement over RIT and vaccines that I felt 10 or so years ago, when I really started researching treatments.
And then the most fascinating part of all -- speculation about where treatments for FL were headed (in 2007). The authors got some things right, but, as I said, I don't think anyone could have predicted 13 years ago where we were headed, specifically.
The authors acknowledge that a better understanding of biology, especially genes, would lead to some new treatments. I'd say this is correct. The "pathway" treatments we have now -- all those inhibitors -- comes from this understanding. The authors also hoped this would lead to better diagnostic tools, though the jury is still out on this one. We're still looking for biomarkers to help predict EFS24 and transformation, but there's nothing definitive yet.
The authors also predict, correctly, that so many new possible treatments will mean carefully considering how to test them all. They suggest things like not always relying on randomized studies (where two equal groups are given two different treatments so a direct comparison can be made). Instead, we might do things like rely on surrogate markers (for example, if a group does well at 2 years, and still at 5 years, we can assume that 2 years will be enough). I'm not sure the field has done as good a job as had been hoped with coming up with better ways to run clinical trials and approve more treatments in a faster way. And maybe that's a good thing -- I'd rather have a solid treatment that is a big improvement on effectiveness and safety than a bunch of treatments that make only small improvements. (In my personal, remember-that-I'm-not-a-doctor opinion.)
The authors also spend a little time on transplants, and whether or not they will be worth the potential problems in 20 years. A good prediction -- transplants are still a valuable tool for many patients, but they seem to be less popular of a choice than they once were, as more targeted treatments with fewer side effects become approved.
Finally, the authors remind us that, in 2007, great improvements had been made in Overall Survival. In the first half of the century, the 5 year survival rate was about 47%. By 2007, it was about 80%. These days, it's about 88%. Still getting better.
So there's your history lesson for today. The big takeaway (besides that we need to start planning for that party in 2025) is that, even in the 12 years since I was diagnosed, researchers have made some big advances. I like to think that, in another 10mor 12 years, we'll have even more advances that we can't even imagine right now. (But some smart researcher probably has already started working on it.)
One last quote from the article: "This is an interesting time for those interested in lymphoma."
Still true, 13 years later.
Many of them have to do with investing in companies that make treatments for Follicular Lymphoma. There are a lot them. I take that as good news -- if people are writing this much about how much money can be made on FL treatments, then things must be looking up for us, right?
Sometimes they are nice articles from local newspapers or TV channels with stories about people with Follicular Lymphoma who are holding fundraisers or running marathons. They are always inspiring. (Occasionally something I have written for another website comes up. I won't lie -- I think it's really cool every time it happens.)
And then there are the links to medical journal articles, or reports about them in sites for oncologists. These are also usually inspiring. It's mostly how I keep up on the latest and greatest news about Follicular Lymphoma.
Which is why it was so strange when an article from a medical journal from 2007 came up in my email. Most of what I get is very current -- posted online in the last day or two. But this one was 13 years old. My guess is that the journal just posted it, or re-posted it to a new site. But I read it anyway, even though it was 13 years old, based on the title:
"Follicular Lymphoma: A Historical Overview," published in the journal Leukemia and Lymphoma.
This was published a little less than a year before I was diagnosed. I was curious about what the state of the field was at that time. And I've read enough medical journal articles to know that there was probably going to be a section that said, basically, "Here is the history -- where we've been -- and now I'm going to tell you where we think the field should go." And that's the interesting part -- did the authors predict the direction things went?
(Spoiler -- they didn't, not exactly, and I don't think anyone could have predicted how FL treatments have developed.)
Here's some early FL history -- Follicular Lymphoma was first identified in 1925 by researchers in New York City. It was first named after them (Brill-Symmers Disease), and was considered benign. It was eventually discovered to be a type of lymphoma. This part is fascinating -- the first two patients with FL were 28 and 32 years old (much, much younger than the age most people are diagnosed with FL these days). They had radiation, and it gave them good results.
But here's the most important thing to come from the article -- Follicular Lymphoma was discovered in 1925. That means its 100th birthday is in five years. WE WILL HAVE A PARTY. You can be darn sure I will still be around in 5 years, and I expect all of you to be, too. I'm going to start planning soon. This Zoom stuff is nice, but I'm envisioning a big get-together, someplace nice, for anyone who can make it. Maybe a bunch of them, all around the world. Weird thing to celebrate, but it's 2020 and that's where we are these days.
There are some other fascinating bits, too (like, in a study of patients diagnosed between 1917 and 1939, 20% died within 2 years of diagnosis, which seems too much of a coincidence when we know today about EFS24 -- about 20% of patients will relapse within 2 years after immunochemotherapy. It was also considered very rare in the Western Hemisphere for the first part of the century, much like it is considered rare in Asia and Africa these days. That could be something environmental, or it could just be that it was hard to diagnose).
More interesting to me is the section on treatments. As I said, this was published a year before I was diagnosed, so it's fascinating to see what was available at that time. The article mentions radiation (mostly useful for stage 1 and 2 disease); Chemotherapy (especially CHOP, CVP, and Fludarabine, which were pretty much the options presented to me -- no Bendmustine at that time. Interestingly, Interferon is mentioned, something that never really caught on in the United States (though I know is still popular in Europe). Also, watching and waiting is discussed under chemo, since there were some studies that compared the two. Bone Marrow or Stem Cell Transplants are also discussed, especially Allo transplants, though the potential problems are also brought up. And then there are targeted therapies, especially Rituxan. Rituxan had only been approved for 10 years, so the article is hopeful that R + chemo would result in a long-term Overall Survival benefit. There is also some discussion of RadioImmunoTherapy, and of vaccines, and of anti-bcl treatments.
All of this brings back memories for me, especially the excitement over RIT and vaccines that I felt 10 or so years ago, when I really started researching treatments.
And then the most fascinating part of all -- speculation about where treatments for FL were headed (in 2007). The authors got some things right, but, as I said, I don't think anyone could have predicted 13 years ago where we were headed, specifically.
The authors acknowledge that a better understanding of biology, especially genes, would lead to some new treatments. I'd say this is correct. The "pathway" treatments we have now -- all those inhibitors -- comes from this understanding. The authors also hoped this would lead to better diagnostic tools, though the jury is still out on this one. We're still looking for biomarkers to help predict EFS24 and transformation, but there's nothing definitive yet.
The authors also predict, correctly, that so many new possible treatments will mean carefully considering how to test them all. They suggest things like not always relying on randomized studies (where two equal groups are given two different treatments so a direct comparison can be made). Instead, we might do things like rely on surrogate markers (for example, if a group does well at 2 years, and still at 5 years, we can assume that 2 years will be enough). I'm not sure the field has done as good a job as had been hoped with coming up with better ways to run clinical trials and approve more treatments in a faster way. And maybe that's a good thing -- I'd rather have a solid treatment that is a big improvement on effectiveness and safety than a bunch of treatments that make only small improvements. (In my personal, remember-that-I'm-not-a-doctor opinion.)
The authors also spend a little time on transplants, and whether or not they will be worth the potential problems in 20 years. A good prediction -- transplants are still a valuable tool for many patients, but they seem to be less popular of a choice than they once were, as more targeted treatments with fewer side effects become approved.
Finally, the authors remind us that, in 2007, great improvements had been made in Overall Survival. In the first half of the century, the 5 year survival rate was about 47%. By 2007, it was about 80%. These days, it's about 88%. Still getting better.
So there's your history lesson for today. The big takeaway (besides that we need to start planning for that party in 2025) is that, even in the 12 years since I was diagnosed, researchers have made some big advances. I like to think that, in another 10mor 12 years, we'll have even more advances that we can't even imagine right now. (But some smart researcher probably has already started working on it.)
One last quote from the article: "This is an interesting time for those interested in lymphoma."
Still true, 13 years later.
Wednesday, July 1, 2020
Please Vote for My Blog!
The WEGO Health Awards are back!
Every year, the awards honor online health advocates from many different patient communities. There are 16 different awards this year, meant to recognize excellence in different social media platforms, as well as broader advocacy work done over time.
This is the fourth year I have been nominated, and it's a very cool experience. One of my favorite parts of being a health advocate is hearing from people in the Follicular Lymphoma community. I love your emails, your comments on the blog, and (I really want to find time to do it again!) your Zoom chatting. I know other advocates feel the same way.
I'd do it even without the awards, but this kind of recognition is nice, too. Some of the support comes from my community, and some comes from other advocates. I am always in awe of what other advocates do, and I really enjoy things like the WEGO Health awards because they give me a chance to recognize other advocates' work, too. It's a great few months to be an advocate.
The way things work is that advocates are nominated for awards (and can continue to be nominated through July, which is how people can add comments to the nominees pages). Also during July, nominees can be "endorsed" by others (which is really the same thing as "voting," but the awards people don't like to call it that). The three nominees in each category with the most votes or endorsements move on to the finals. A separate panel of judges also look at the nominees and choose three more finalists. Those six finalists are then looked at by another group of judges, who select the winners in each category.
This year, I have again been nominated for three awards:
If you would like to endorse me for any of these, or all three, the easiest thing to do is click on this link:
https://www.wegohealth.com/LymphoBob/awards
It will take you to my nominee page. Look for this box:
Click on "Endorse This Patient Leader" and it will ask you for your name and email address (you'll need to provide this so they can verify that you have voted -- only one vote per email!). From there, it should be pretty easy to figure out.
Thank you for your support. I've said for a long time that I'd probably keep writing the blog even if no one read it, because it does me good to keep up on things. But hearing from some of you that I have been able to help you makes it that much more worth it.
Stay well.
Every year, the awards honor online health advocates from many different patient communities. There are 16 different awards this year, meant to recognize excellence in different social media platforms, as well as broader advocacy work done over time.
This is the fourth year I have been nominated, and it's a very cool experience. One of my favorite parts of being a health advocate is hearing from people in the Follicular Lymphoma community. I love your emails, your comments on the blog, and (I really want to find time to do it again!) your Zoom chatting. I know other advocates feel the same way.
I'd do it even without the awards, but this kind of recognition is nice, too. Some of the support comes from my community, and some comes from other advocates. I am always in awe of what other advocates do, and I really enjoy things like the WEGO Health awards because they give me a chance to recognize other advocates' work, too. It's a great few months to be an advocate.
The way things work is that advocates are nominated for awards (and can continue to be nominated through July, which is how people can add comments to the nominees pages). Also during July, nominees can be "endorsed" by others (which is really the same thing as "voting," but the awards people don't like to call it that). The three nominees in each category with the most votes or endorsements move on to the finals. A separate panel of judges also look at the nominees and choose three more finalists. Those six finalists are then looked at by another group of judges, who select the winners in each category.
This year, I have again been nominated for three awards:
- Best in Show: Blog
- Patient Leader Hero
- Lifetime Achievement.
If you would like to endorse me for any of these, or all three, the easiest thing to do is click on this link:
https://www.wegohealth.com/LymphoBob/awards
It will take you to my nominee page. Look for this box:
Click on "Endorse This Patient Leader" and it will ask you for your name and email address (you'll need to provide this so they can verify that you have voted -- only one vote per email!). From there, it should be pretty easy to figure out.
Thank you for your support. I've said for a long time that I'd probably keep writing the blog even if no one read it, because it does me good to keep up on things. But hearing from some of you that I have been able to help you makes it that much more worth it.
Stay well.
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