Monthly Archives: November 2015

Mysteries…

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FullSizeRender-2FullSizeRender-3The conclusion of Allistaire’s biopsy is well, sort of inconclusive.  What we can say definitively after a week of numerous tests on the sample from her lungs is that it is not leukemia, not fungus and not bacteria.  Obviously this is all good news, actually fantastic news!  However, there is something going on in there.  We seem to be down to two remaining possibilities not previously considered.  Either the spots are evidence of a recovering infection or are evidence of Cryptogenic Organizing Pneumonia (COP).  The cells are described as hemosiderin laden macrophages.  Actually, the description of the tissue is far more detailed than that – I will include it below just so you can be in awe of both our amazing bodies and of the task of the pathologist.  In a way it would be surprising if the spots are evidence of a recovering infection given that they were not present on the previous CT, nor has she had any symptoms.  On the other hand, the sort of COP that Allistaire could have is actually a complication of a bone marrow transplant typically seen in adults and is a process of GVHD (Graft Versus Host Disease).  Allistaire did have COP in the spring of 2014 and was successfully treated with steroids.  Again, Allistaire has absolutely no symptoms of anything happening in her lungs, just this sole indication derived from the CT.

The plan is to re-scan next Wednesday, 11/25.  If the spots are the same or worse, she will likely be seen by a pulmonologist at SCCA (Seattle Cancer Care Alliance).  Dr. Cooper is also consulting with Dr. Carpenter, who is a pediatric BMT (bone marrow transplant) doctor who specializes in GVHD.  He is the doctor that directed the treatment of her previous COP.  It is not an optimal time right now for Allistaire to be on steroids if this is the required treatment.  Steroids suppress the immune system which added to the suppressive effect of chemo is a double whammy in terms of vulnerability to infection.

As of today, Allistaire has started what we hope and pray is her last round of chemo before transplant.  Just like the previous two rounds, she will start with five days of Decitabine followed by Mylotarg.  The exact number of Mylotarg doses is still to be determined.  It sounds like given the hoped for timing of transplant, it may make more sense to do only two doses.  Dr. Cooper and Dr. Bleakley are working together to sort out all the details.  Oh, I should also mention that Allistaire’s cytogenetics from her bone marrow also show no evidence of the MLL rearrangement by FISH which means no evidence of AML in her marrow.  This is in keeping with the clear results from the Flow Cytometry test.

As for today, Allistaire and I are delighting in having Solveig with us for a week and a half.  She flew in yesterday and Sten’s parents will drive out on Tuesday.  Sten will fly in on Thanksgiving morning and Allistaire will get her first dose of Mylotarg.  The bummer thing is that it seems Solveig has just started showing symptoms of a cold.  I don’t know how Allistaire will avoid it but I so hope she can.  We are looking forward to Thanksgiving with the joy of so much family with us.

 

Lung Biopsy – Microscopic Description:

H&E stained sections demonstrate lung with large foci of atelectasis and collapse intersected by bands of septa with increased fibrosis and vessels with hypertrophic walls.  There are increased macrophages within alveolar spaces, many of which contain hemosiderin or foamy material.  Hemosiderin laden macrophages are particularly prominent around bronchioles.  Also conspicuous are scattered small and large droplets of exogenous lipoid material in airspaces.  Well-inflated lung parenchyma in well-expanded areas shows thing delicate alveolar spat without fibrosis or significant inflammation.  Inflammation is patchy, mild to moderate and airway-centric, consisting predominantly of lymphocytes and plasma cells admixed with few neutrophils.  Infiltration of inflammatory cells in the bronchial epithelium is seen, and there is associated plugs of fibroblastic tissue (organizing pneumonia) as well as mucostatsis in airways.  Bronchioles also demonstrate smooth muscle hyperplasia and sub-epithelial fibrosis.  Many airways have moderate to marked luminal occlusion by well-established collagen deposition (constrictive/obliterative bronchiolitis) as highlighted by Movat pentachrome stain.  There is mild medial thickening of pulmonary arteries and veins show intimal fibrosis as well as muscular hypertrophy.  No atypical cellular population is seen, confirmed by CD15 and lyzozyme stains.  Viral cytopathic changes are absent.  Fungal and bacterial stains are negative.

Lung Biopsy

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IMG_1792I met with Dr. Cooper for Allistaire’s clinic appointment last Wednesday afternoon.  The results of the week’s testing were mixed.  The bone marrow test showed no leukemia detectable by Flow Cytometry which is an awesome improvement from prior to this round.  Previously the Flow test showed about 3% and the cytogenetics FISH test showed 6%. We don’t have cytogenetics back yet from this most recent bone marrow test.  The PET/CT affirmed what the brain MRI showed from two weeks ago with significant improvement in the chloromas in her sinuses.  The trouble is, there are also spots in her lungs that have showed up.  Because the resolution of the CT done with the PET is low, Dr. Cooper wanted a high-resolution CT of her lungs.  It took a mere 15 minutes to leave clinic, check in with radiology, walk back to the CT machine, get Allistaire loaded in, hold her breath at the right time and we left the hospital arriving back at Ron Don.

While I was totally relieved to hear good Flow Cytometry results for her marrow, the spots in her lungs pose a major, major problem.  There are three options – they are chloromas/leukemia, fungus or bacterial.  Dr. Cooper relayed that Dr. Bleakley, the BMT (Bone Marrow Transplant) doctor said that if these are chloromas they indicate an incredibly aggressive cancer (given that the chemo isn’t successful at keeping her cancer down even for a short time) and she will probably not be offered a transplant.  No transplant obviously means the end for Allistaire.  The other options, fungal and bacterial, represent infection which would require some aggressive treatment.  Allistaire’s bone marrow is so beaten down that it is barely recovering from the last round of chemo.  Her ANC (Absolute Neutrophil Count) was 64 as of Sunday’s labs.  Today is about Day+48 of this round of chemo.  Typical bone marrow recovery is an ANC of 200 by Day+28.  This means she has very few white blood cells to fight any infection.  So while she has no symptoms of infection, she also has very little to fight with and would have even less once another round of chemo begins.  In a way we must hope that these spots are infection because this at least gives her an option to go forward.

Given that it is imperative to know the nature of these spots, Dr. Cooper said doing a lung biopsy would be necessary, but of course if was my choice.  My choice?  I suppose so, but to say no to the biopsy would equate with choosing to be done.  Amazingly, the biopsy was able to be scheduled for Friday afternoon, with the plan to go into clinic in the morning to get platelets first.  Strangely, Allistaire’s blood pressure was incredibly low, even lower than its normal low.  The strategy of the heart failure team is to push Allistaire’s cardiac meds just as far as they can without totally bottoming out her blood pressure.  They continue to titrate up her meds every Wednesday, alternating between going up on the dose of Entresto and Carvedilol.  So while the purpose of the cardiac meds has nothing to do with trying to lower her blood pressure, this is the direct side-effect.  On Friday her pressures were in the low 60s over mid to low 30s.  More typical blood pressures for Allistaire are 80s over 40s.  She was examined by the nurse practitioner and the clinic attending doc who both agreed she looked great – bright, energetic, engaged, good capillary refill and strong pulses.  Her pressures came up slightly after the platelets.

Finally it was time for the biopsy and the surgeon explained that first Allistaire would go to CT where the Interventional Radiologist would use CT to guide the placement of a needle within which there is a small wire.  Once the IR doc locates the spot in the lung that is the target of the biopsy, he places the needle and then removes it, leaving the wire.  She would then be transferred to the OR where the surgeon would remove the spot using a tool that places staples on two sides and has a blade on one side to cut out the spot.  He said that most likely she would leave surgery with a chest tube to help drain fluid rather than allowing it to build up within the pleural space while the hole in the lung sealed back.  He said it could take anywhere from a few days with the chest tube up to a few weeks and that it would be quite uncomfortable.  As I was about to leave Allistaire in CT as she had just fallen asleep, the anesthesiologist looked concerned.  She told me that she wasn’t sure they would able to continue with the procedure if Allistaire’s blood pressures did not remain stable given how low the base line pressure was.  As I walked out of the room with a weighty heart, 59/30 shone green on the monitor.  Would she make it through this procedure?  How desperate we are to know what is going on in there.

Thankfully, all went well both with her pressures and the procedure.  She was already awake by the time she was transported from the OR to recovery.  Soon she began to complain of burning pain in her chest.  She was given a dose of Dilaudid and began to calm down.  An X-ray a few minutes later confirmed that the pain she was having was from the chest tube tunneled under her skin.  Her oxygen saturations were dropping every so often because she didn’t want to take deep breaths due to the pain from the chest tube.  She was transferred up to the Cancer Unit Friday evening where she was given morphine every 2 hours.  Allistaire was very quiet and went in and out of sleep as she watched movies.

Saturday began with an x-ray to look for fluid, air or gas filling the pleural space.  I was surprised to learn that because there was minimal drainage from her chest tube and the X-rays were looking good, the surgeons decided to turn off the suction on her chest tube.  They would check it again in four hours and then take another X-ray.  If all looked good, they planned to pull the tube.  So around 5pm, the surgeon, nurse and I strategized on how best to pull the tube.  I made a commitment to Allistaire many months ago in the ICU to always tell her if something scary or painful was going to happen.  But I’ve also learned that for Allistaire’s sake, it is best to tell her as last-minute as possible as she often gets really worked up with a lot of anticipatory fear.  The nurse quickly ran a dose of Dilaudid over 5 minutes and I curled up next to her in bed.  I told her the surgeon was here to remove the tube because her lung was looking so good.  He would remove the gauze, cut the stitches and when he was ready to pull the tube, he would tell her to blow out of her mouth which helps to keep air from entering the body in the small space of time between when the tube is pulled and the dressing is placed.  Allistaire was terrified and kept asking when did she need to blow.  The truth is I don’t even think she felt the tube come out given that there was no indication it was out and suddenly it was all over.  She did a great job, she was very brave.

From this point, Allistaire had another X-ray four hours later and then at the 24 hour mark from the time the tube was pulled.  Because all continued to look good, she was able to be discharged yesterday evening.  She only needed one dose of pain meds once the tube was pulled.  The day was fairly uneventful with the exception of being given some misinformation about results of the biopsy.  I was told that a person from ID (Infectious Disease) said that this (the spots in her lungs), looked more like a disease process.  While the attending doctor was later able to clear this up, saying that there were absolutely no results yet, I spent several agonizing hours contemplating the reality that Allistaire’s options had finally come to an end.

I can’t be fake with Allistaire.  She is so intuitive, so sensitive, so incredibly sweet and tender.  I couldn’t stop crying.  I just stared out the window at the steel gray clouds interspersed with late afternoon sunshine.  “What’s wrong, Mommy?”  I tell her the spots in her lungs look like more sickness and if this is true, she can’t have her transplant.  The other day she asked why she can’t just keep getting tubie medicine.  I had to explain that her body just can’t handle it.  How can I explain to a 5-year-old that inside her sweet tummy are kidneys and a liver and a heart and lungs and white blood cells?  How do I explain that iron builds up in your body with every transfusion of red blood and eventually you will die from iron poisoning.  This is not a chronic illness.  This is an acute, deadly disease.  “Your tubie medicine is poison, Allistaire, it kills cancer cells but also hurts your body.”  On this day, as I cradle her warm little body, her soft luxurious curls against my cheek, I think of what my friend Esther wrote.  About the desperate need to soak her in, to burn every memory into my brain, so that when she is gone, I can find her again, if only in memories.  But I can’t, I can’t.  It isn’t enough.  I hold her tight, desperate not to let her go.  “I just hope I won’t notice it happening,” Allistaire tells me about the fact that she may die.

I let her go back to her movie and her model magic.  I stare out again at the gray.  What is the best way to let her die?  Do we even try another round of chemo?  Do we try to extend her life just as long as we can?  But might this mean letting that wretched tumor grow in her face?  All that pain.  I think back to four years ago.  These were the dreary November days that she just slept and slept.  She would be asleep for five hours in her crib taking her nap.  I would debate with myself whether or not to go wake her or just let her sleep.  I feared finding her dead in her crib.  She wouldn’t crawl up the stairs anymore.  She had little interest in eating.  On December 1, 2011, I would first learn the word, “hematocrit.”  Her’s was 9, just a mere 25% of her red blood.  She had absolutely no energy and her heart beat fast like a little bird, desperate to pump those meager cells around her body.  Maybe this is the way, I consider, just let her go quietly.  She wouldn’t even notice.  She would just fall asleep.  Her heart wouldn’t be able to keep up.  Maybe this was the most gentle way to let her go.

I still don’t have biopsy results.  In fact, I didn’t expect to get them until today or tomorrow anyway.  But soon I will know.  I woke up in the night.  What do we do if they say no to a transplant?  I’ve thought of so many other desperate stories where they allowed transplant, even were there was little chance it would work.  Why deny Allistaire the chance?  This one last chance.  If they say no here, do we try taking her somewhere else?  These are the doctors in whom I have placed my trust.  They have earned my respect.  They know Allistaire.  They genuinely care for her.  Do I just disregard their counsel, their decisions and rush out into the fray, unwilling to lay down this battle?  The doctors have always told me, you will know when it’s time.  But this?  At this point I feel no peace, no rest in stopping.  It doesn’t feel clear at all.  I always hoped, assumed, it would be clear, that if at last there were no more options, no more open doors, I could at last say okay.

As always, the world operates on a calendar, on schedules, on days of the week.  I heard my first Christmas song three days ago and all I felt was shock.  Has the world again shifted, are we already at another holiday season?  Sten and Solveig and Sten’s parents are coming for Thanksgiving.  In times past, we always cut down our Christmas tree the day after Thanksgiving, one of my very favorite traditions.  I always looked forward to that day, the day I would pack away all the oranges and browns of Fall and pull out the silver and glittery of Christmas.  All just seems desolate, empty.  I just wanted this one last chance for Allistaire.  Just this one chance.  Oh God.  Please.IMG_1804 IMG_1802 IMG_1800 IMG_1798 IMG_1796 IMG_1795 IMG_1794 IMG_1791 IMG_1790 IMG_1786 IMG_1784 IMG_1782 IMG_1750 IMG_1749

Numbers, Wild Numbers

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IMG_1461IMG_1466IC_Obliteride_080715_GasWorksKickoff_0029100MileStart-640

1975

2013

2,650,000

6,800,000

8,000,000

So something cool happened.  Forty years ago, in the year 1975, I was born.  I know, sweet, huh?  Just joking.  I mean I’m pretty stoked I was born but what my parents could not have imagined as they gazed down at their newborn baby girl’s little face was that something else significant had just been created.  Little did they know that blue-eyed baby girl cradled in their arms would one day desperately need what also had its beginning in 1975.  In many respects I think it is grace that we do not know the future, that we don’t have to carry burdens in the present of situations yet to come.  At that moment of my birth there was only joy, well my mom would probably say a little pain too.  And yet isn’t it amazing that long before we have a specific need, the provision is often already on its way to being available and ready for us? And so it was that in 1975, Fred Hutchinson Cancer Research Center came to be and would one day dramatically intersect the life of that little baby girl and her baby girl.  Beautiful.  Makes me smile BIG!

In the spring of 2013, there was a blue-eyed feisty three-year old girl named Allistaire.  Turns out she had an aggressive type of leukemia that just wouldn’t back down in the face of every type of chemo thrown at it.  It had come back after lying dormant after standard treatment and this time it was winning, filling her marrow and infiltrating the rest of her body with numerous tumors.  The doors just kept slamming closed.  But then, but then…a door opened.  Allistaire had the amazing opportunity to have her disease filled marrow obliterated and then rescued with an infusion of donor bone marrow stem cells from a woman in Germany.  This was only possible because of a wondrous clinical trial through Fred Hutch.  Had it not been for that trial, for that single open door, there is no doubt Allistaire would be dead in the ground right now.

Time after time Allistaire has been the blessed recipient of the expertise and amazing research through Fred Hutchinson Cancer Research Center.  I will always be indebted to that institution and its many phenomenal doctors and support staff!  It is my joy to commend them to you and to keep seeking to add to their ability to propel research forward and provide more open doors for children and adults alike who find themselves facing that wretched beast Cancer.

And WOW!  WOW!  Look at what we’ve been able to do!!!!!  This year, in August 2015, thanks to your incredible generosity, compassion and support, our Obliteride Team Baldy Tops raised $38,000!  In total over the past three years riding in Obliteride, our team has raised nearly $60,000 for cancer research at Fred Hutch.  This year’s ride raised $2,650,000, totaling $6,800,000 since the inaugural ride in 2013.  One hundred percent of that $6,800,000 goes directly to cancer research at Fred Hutch!  It makes me giddy.  Sometimes one’s efforts feel small.  It’s hard to put yourself out there and ask people to give of resources they could spend on themselves, and instead give it away for the betterment of others.  Then again, you never know when you might find yourself in the desperate position of needing another open door in your own battle against cancer.  When we put our efforts together they can have a BIG impact!!

Would you like to join us?  Our team this year was super fun and included Sarah from Utah – an amazing woman I had never actually met until the morning of Obliteride.  You should have seen her face when she finished her 50 miles – a beaming exuberant smile!  Also on our team were two fantastic nurses, Lysen and Adrienne, from the Cancer Unit at Seattle Children’s where Allistaire receives treatment.  Adrienne and her awesome dad rode on an old tandem bike (and I do mean old).  Carrie, our amazing financial counselor at the hospital joined us as well along with her friend Eric, a local business man who wants to give back.  And of course I had my dear sweet sister-in-law Jo by my side along with my oldest friend, Emily.  Jo’s sister, Annie, also joined us.  Her little baby boy, Marzio and husband, Franky cheered us on.  It is such an amazing experience to be in a swarm of people gathered together for one purpose, each brought to that day by their unique stories.  Obliteride has put together a short little video of this year’s ride to give you a taste of the experience.  You’ll get to see several shots of our team (I have on a blue helmet you see a few times.) Click HERE.

The beauty is you don’t have to be a cyclist to participate in Obliteride.  There are rides from 10 miles to 150 miles, from quick and easy, to covering two days and lots of hard-core hills.  Wherever you are on the cycling spectrum, there’s a place for you to have fun and give directly to cancer research.  Even your kids can get involved with the special kid’s ride.  The 2016 ride is over the weekend of August 12-14th, so mark your calendars to ride with us or be a volunteer.  Registration will open early 2016 and of course I’ll keep you updated!  If you’re interested in being on our team Baldy Tops, please simply leave a comment on this post and I’ll include you in my Obliteride emails.  Wouldn’t it be awesome for our team to reach the $100,000 mark with the 2016 ride?!  I can’t wait!  Here’s another fun video to give your more info on how to get involved in Obliteride.

This year is drawing to a close and you may be considering where to give your remaining 2015 donations.  While it isn’t yet time to fundraise again for Obliteride, you can still give to amazing cancer research at Fred Hutch.  One specific way is to support Dr. Marie Bleakley’s work.  She has been one of Allistaire’s primary bone marrow transplant (BMT) doctors at Fred Hutch for the past several years.  She is the BMT doc who is directing Allistaire’s upcoming (hoped for) transplant.  Like most of Allistaire’s doctors, not only does she do an incredible job clinically caring for patients, but she does amazing research.  One focus of her research is TCRs (T-cell Receptor T-cells).  You will remember that this is the sort of immunotherapy Allistaire received with her WT1 T-cells.  In the HA-1 T-cell immunotherapy that Dr. Bleakley is designing there are specific matching and mismatching requirements of the donor and patient which on one hand limit their applicability to a wide range of patients, on the other hand, they are not limited solely to patients with AML but could benefit patients with a variety of types of ALL (Acute Lymphoid Leukemia) and Lymphoma as well, thus expanding their impact.  Dr. Bleakley says that, “There are actually numerous targets like HA-1 and different targets will work for different patient-donor pairs. We are trying to build a toolbox of TCRs so that we can ‘type’ the patient and donor and figure out which TCR will work for them.”  This is personalized, targeted, sophisticated beautiful cancer treatment.

Dr. Bleakley has already been awarded a Bio Therapeutic Impact Grant of $682,000 from Alex’s Lemonade Stand (ALS) whose vast majority of funding goes directly to pediatric cancer research. I am told that 85 cents of every dollar donated goes to program and research grants with the vast majority of that going to the research end. Their program grants go to family’s to provide one lifetime grant of about $1,400 which we ourselves received two years ago in the form of plane tickets home for Allistaire and I.  Dr. Bleakley is able through Alex’s Lemonade Stand to raise up to an additional $25,000 in donations through the end of 2015. For every dollar up to $25,000, ALS will match one to one. So in total she could raise $50,000 additional to go toward her research.

This is an incredible opportunity to fast-track her research in the lab to actual patients.  The next step for her research is to take what they have been doing in the lab and bring it to a GMP (Good Manufacturing Process) lab. This independent lab would, with the aid of her research assistants, recreate their work in order to determine the safety and quality of the product they say they are producing. She said it’s like a dress rehearsal for the real process in which they would prepare the cell product for the patient. The information is taken and included in an IND (Investigational New Drug) Application for the FDA to approve. Once approved, they can then move forward to offering an actual clinical trial to patients. Basically they are at the point of taking their research in the laboratory and offering it as treatment to patients – that means an open door for patients with leukemia and lymphoma!  An open door!  You could help open that door.  To learn more about her research click HERE.  To donate and have your dollars matched one to one up to the goal of $25,000, click HERE.

You know what…At last count, Allistaire’s cancer treatment has cost just shy of 8 million dollars.  That’s more money than all riders have raised in total over the three years of Obliteride.  That is a crazy, mind-blowing number!  My jaw drops every time I think of that number.  Wouldn’t it be WAY COOLER if we could invest in research upfront that would reduce the cost of treatment, reduce the suffering, reduce the incredible investment of time of Allistaire’s life and our family’s lives fighting this fight?  When we put money upfront to accelerate research, we open more doors!  What if we didn’t have to rely on chemotherapy that isn’t targeted and takes down hearts and lungs and kidneys and livers and ovaries with the cancer cells.  What if there was a way to deliver radiation so that it only killed tumors and not brains.  What if surgeons could “see” exactly where tumor cells stopped and healthy cells started, getting all the cancer and sparing the rest? Wouldn’t it just be mind blowiningly awesome to use the incredibly complex, beautiful immune system you already have in your body to effectively and totally wipe out every last cancer cell so that “relapse,” is word never again uttered!  When we put our money and effort into research, it isn’t just one patient that is benefited.  Who can know how many people will be blessed by each step forward in cancer research.  And this is a world-wide endeavor!  Do you know that amazing minds are at work all over this earth trying to untangle the mysteries of cancer?!  Israel, Germany, China, Italy…What is learned here carries value across the world and their efforts likewise bless us!  Do you know that Fred Hutch has a cancer treatment clinic in Uganda?

As I have said many times, there are many worthy places to give of your time and money, many struggles on this earth that deserve and need our attention.  It just so happens that cancer came barreling into my life and so it does for many, many of us.  Cancer will touch us all, if not directly in our flesh, then most certainly in that of someone dear to us.  One in three women will get cancer in their lifetimes as will one in two men.  Thank you for the great swelling of your compassionate hearts that listened and responded in generosity and love.  May you find many open doors!!!

As for our little bright love, Allistaire Kieron Anderson, well, she thrives, she runs, she hops, she laughs silly little giddy laughs and she told me today that the numbness in her face is finally gone.  She looks incredibly good.  Only every now and then can I detect that her right eye is slightly off.  Yesterday she had a bone marrow test and today she had her PET/CT.  We should know results soon.  Hopefully the general trajectory going forward is one more round of chemo which will include Decitabine and Mylotarg again, though likely only one or two doses of Mylotarg this time instead of three.  Then, God willing, she will have her transplant.

We’ve been at this point before.  I am no fool to believe the road ahead is necessarily clear of barricades.  It as though she walks through a field replete with land mines. To get across to the other side will take a miracle, so fraught with danger is the road ahead.  Even yesterday, she had an echocardiogram which reported out an Ejection Fraction of 34 versus 45 last time.  I don’t know how the BMT doctors will interpret this.  The cardiologists say her heart function looks the same as it has on the last two echos despite variance in the numbers.  Thankfully her cardiac MRI showed no scarring and affirmed great improvement in her heart.  Going forward with chemo always opens the door to infections.  Two and a half weeks ago she went inpatient due to an infection and the next day she had a separate issue with an extreme rise in her liver function numbers we finally concluded was due to her anti-fungal, posaconazole.  Her ALT and AST were 1,156 and 1,450 respectively, the normal high being 40.  It has been imperative to get these numbers down and get her liver happy again as Mylotarg’s one direct toxicity can be to the liver both in the setting of when it’s given and in transplant.  Just getting to transplant is an incredible undertaking, then there’s the transplant process itself which holds many extreme dangers.  If you get past all of that, you still have to contend with the possibility of GVHD and relapse.  Thank you Lord that you have used these past four years to help me learn more and more how to walk day by day.

To learn more about the fascinating history and endeavors of Fred Hutchinson Cancer Research Center, click HERE

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