Wednesday, 17-Sep-2008
Got a reply that raised questions I had not addressed:
Kris' long term disability went through so, we are covered. Not only that but, she was approved for Social Security disability which is odd given that we were told flat out it takes a year to go through!
Chemotherapy... we thought we were done, and in a way we are, in a way we are not. Today, Kris goes in for an infusion of Herceptin. Apparently the plan was to do a year of Herceptin all along. The good news is that as these drugs go, Herceptin is 'gentle' so her hair and nails will grow back and she shouldn't have any side effects to speak of. Dr. Moran apologized because as he was telling us this he realized that he'd lead us to believe we were done with Chemotherapy. The reason is that he doesn't think of Herceptin as Chemotherapy whereas he does think of Taxotere and Xeloda (etc) as Chemotherapy. Largely this is due to the side effects of the other drug therapies and lack of side effects from Herceptin.
Kris is as well as can be expected given the news about Nikki.
General apologies for not posting for a while. It's been hectic for me of late and I will endeavor to do a better job of keeping the posts up to date.
Wednesday, September 17, 2008
Kris Dave and the Lumps: Final Analysis, pre surgery
Tuesday, 16-Sep-2008
Met with Dr. Moran who had the results of the Cancer Conference. Dr. Antel had done a lot more digging and presented his information. The general consensus of the Dr.s attending was that we should not do radiation therapy in this case. The Pet and MRI scans showed good results but there was some indication of a presence of... something, which could still be cancer. We'll know more when the tissue is biopsied post surgery.
Based on this we're in the process of confirming the 10th of October as the date for the mastectomy and reconstructive surgery. We meet with the surgeons in the very near future to solidify these plans. To recap; the reconstruction is a tram flap surgery which means they will take tissue from Kris stomach to reconstruct her breast with. This also means we need to see Dr. Kuisle (the plastic surgeon) about a week in advance for an outpatient procedure which will restrict the blood flow to the tram flap tissue to a predetermined set of vessels. This is to make sure he can use those vessels during the reconstruction procedure.
According to Dr. Moran, Kris will likely go into surgery Friday the 10th, which will be 3 or 4 hours. She'll stay in the hospital likely until Sunday the 12th. I expect her to be on bed rest for a day or three after that, so, she might be ambulatory Wednesday. We'll know more after we talk with the surgeons.
Somewhat side news is that we've got some very bad news about our cats. Our youngest, Nikki who is exactly one year old, has been diagnosed with FIP (Feline Infectious Peritonitis). This disease is highly contagious and insidious in that there is no way to prevent it, nor detect it until it's full blown and it's always fatal. We will be putting Nikki down this morning and will have to watch the rest of our cats for the rest of their lives to see if they are infected. As time goes by and they are not symptomatic, the risk that they have the disease decreases. However, we can never know that they don't have it as the disease can lay dormant for years before expressing itself. Since our cats are strictly indoors and have never been socialized with other cats, the only likely source for infection is the cattery we purchased Nikki from. It's possible to have the disease transferred at a Vet, but, since Vets are aware of how devastating this disease is, they tend to be very careful and thus the odds of Nikki getting the disease from her recent visit there are very slim.
While I do not want any of you to get the impression that I don't care for our cats or that I'm being callous about this, my biggest concern is the impact of this on Kris. Stress is a known issue with triple negative breast cancer and this is the very definition of stressful.
Met with Dr. Moran who had the results of the Cancer Conference. Dr. Antel had done a lot more digging and presented his information. The general consensus of the Dr.s attending was that we should not do radiation therapy in this case. The Pet and MRI scans showed good results but there was some indication of a presence of... something, which could still be cancer. We'll know more when the tissue is biopsied post surgery.
Based on this we're in the process of confirming the 10th of October as the date for the mastectomy and reconstructive surgery. We meet with the surgeons in the very near future to solidify these plans. To recap; the reconstruction is a tram flap surgery which means they will take tissue from Kris stomach to reconstruct her breast with. This also means we need to see Dr. Kuisle (the plastic surgeon) about a week in advance for an outpatient procedure which will restrict the blood flow to the tram flap tissue to a predetermined set of vessels. This is to make sure he can use those vessels during the reconstruction procedure.
According to Dr. Moran, Kris will likely go into surgery Friday the 10th, which will be 3 or 4 hours. She'll stay in the hospital likely until Sunday the 12th. I expect her to be on bed rest for a day or three after that, so, she might be ambulatory Wednesday. We'll know more after we talk with the surgeons.
Somewhat side news is that we've got some very bad news about our cats. Our youngest, Nikki who is exactly one year old, has been diagnosed with FIP (Feline Infectious Peritonitis). This disease is highly contagious and insidious in that there is no way to prevent it, nor detect it until it's full blown and it's always fatal. We will be putting Nikki down this morning and will have to watch the rest of our cats for the rest of their lives to see if they are infected. As time goes by and they are not symptomatic, the risk that they have the disease decreases. However, we can never know that they don't have it as the disease can lay dormant for years before expressing itself. Since our cats are strictly indoors and have never been socialized with other cats, the only likely source for infection is the cattery we purchased Nikki from. It's possible to have the disease transferred at a Vet, but, since Vets are aware of how devastating this disease is, they tend to be very careful and thus the odds of Nikki getting the disease from her recent visit there are very slim.
While I do not want any of you to get the impression that I don't care for our cats or that I'm being callous about this, my biggest concern is the impact of this on Kris. Stress is a known issue with triple negative breast cancer and this is the very definition of stressful.
Sunday, September 14, 2008
Kris, Dave and the Lumps: Tests, tests and more tests
Monday, 8-Sep-2008 to Wednesday, 10-Sep-2008
Busy week. Kris went to a Pet scan and an MRI one of which had to be rescheduled at the last minute. As a reminder, the scans are to see how well the Chemo Therapy did and to see if it's feasible to go through radiation treatment as a followup. We're actually hoping that we don't have to do radiation. Partially because it's an uncomfortable treatment, partially because it implies that things haven't gone as well as they can, and in no small part because it means delaying the reconstructive surgery which means delaying putting all of this behind us.
Thursday, 11-Sep-2008
Met with Dr. Antel who is our Radiologist. He revealed that a lymph node was caught up in this mess which is not truly in the area considered to be the left breast. It's still in the left chest wall area, just not directly in what's considered to be the set of lymph nodes associated with that breast. The implications I don't like are that this means the cancer moved beyond the left breast. Dr. Antel was not actually prepared with an answer. He'd consulted with two of his colleagues he has a lot of respect for and they gave him split answers. One, with a lot of experience, stating that he'd simply not do the radiation treatment at all. The other saying that it looked to be a good idea.
He went on to explain that treating patients in whom cancer had reoccurred with a second bout of radiation was new. There is apparently a study out with about 8 years behind it wherein patients were treated to a second round of radiation and studied for one year following the treatment and the results were quite good. The Numbers are that for a first round treatment they give about 5000 rads and this reduces the chance of recurrence from 20% to 30% down to 10% to 15%... about half. With a second round treatment, they would reduce the area they would radiate so that rather than hitting the whole upper left chest area, they would hit only the breast area and go up high enough to catch the one lymph node and they would also reduce the radiation to about 4500 rads. Further, they would use an electron stream as opposed to the normal X-ray radiation. Electrons have a more shallow penetration. While he can not guarantee that Kris lungs will not be affected this time, the chances of them being affected are greatly reduced, if not eliminated. Basically Legalese for there really is no chance but, it's radiation, we can't give guarantees. The downside is that there is about a 5% chance of complications due to the radiation. Specifically, there could be tissue killed other than the cancer. This means that tests will have to be performed after the radiation and if there is dead tissue, another surgery to remove it will be required. It also means that they can't perform the reconstructive surgery since radiation treatment would effectively kill the tissue used to reconstruct the breast.
We've not yet decided what to do. In fact, Dr. Antel isn't looking for a decision yet. He's going to contact folks from the study he quoted, among others, with specific questions related to our case. He's also waiting for the local cancer board to meet and discuss our case Tuesday. Kris and I meet with Dr. Moran Tuesday to discuss what comes out of the cancer board meeting later Tuesday.
More after Tuesday...
Busy week. Kris went to a Pet scan and an MRI one of which had to be rescheduled at the last minute. As a reminder, the scans are to see how well the Chemo Therapy did and to see if it's feasible to go through radiation treatment as a followup. We're actually hoping that we don't have to do radiation. Partially because it's an uncomfortable treatment, partially because it implies that things haven't gone as well as they can, and in no small part because it means delaying the reconstructive surgery which means delaying putting all of this behind us.
Thursday, 11-Sep-2008
Met with Dr. Antel who is our Radiologist. He revealed that a lymph node was caught up in this mess which is not truly in the area considered to be the left breast. It's still in the left chest wall area, just not directly in what's considered to be the set of lymph nodes associated with that breast. The implications I don't like are that this means the cancer moved beyond the left breast. Dr. Antel was not actually prepared with an answer. He'd consulted with two of his colleagues he has a lot of respect for and they gave him split answers. One, with a lot of experience, stating that he'd simply not do the radiation treatment at all. The other saying that it looked to be a good idea.
He went on to explain that treating patients in whom cancer had reoccurred with a second bout of radiation was new. There is apparently a study out with about 8 years behind it wherein patients were treated to a second round of radiation and studied for one year following the treatment and the results were quite good. The Numbers are that for a first round treatment they give about 5000 rads and this reduces the chance of recurrence from 20% to 30% down to 10% to 15%... about half. With a second round treatment, they would reduce the area they would radiate so that rather than hitting the whole upper left chest area, they would hit only the breast area and go up high enough to catch the one lymph node and they would also reduce the radiation to about 4500 rads. Further, they would use an electron stream as opposed to the normal X-ray radiation. Electrons have a more shallow penetration. While he can not guarantee that Kris lungs will not be affected this time, the chances of them being affected are greatly reduced, if not eliminated. Basically Legalese for there really is no chance but, it's radiation, we can't give guarantees. The downside is that there is about a 5% chance of complications due to the radiation. Specifically, there could be tissue killed other than the cancer. This means that tests will have to be performed after the radiation and if there is dead tissue, another surgery to remove it will be required. It also means that they can't perform the reconstructive surgery since radiation treatment would effectively kill the tissue used to reconstruct the breast.
We've not yet decided what to do. In fact, Dr. Antel isn't looking for a decision yet. He's going to contact folks from the study he quoted, among others, with specific questions related to our case. He's also waiting for the local cancer board to meet and discuss our case Tuesday. Kris and I meet with Dr. Moran Tuesday to discuss what comes out of the cancer board meeting later Tuesday.
More after Tuesday...
Wednesday, August 27, 2008
Kris, Dave and the Lumps: The weeks before surgery #1
I've been a bit remiss, here is me catching up:
Monday 25-Aug-2008:
Kris met with Dr. Jones who was happy to note that the wound is finally healing! We have hopes that by the time it heals... well, we'll have had the port out and a new wound to heal in its place! Everything looks good from the surgeons point of view. He mentioned that they are discussing Kris' case at the cancer board meetings with an eye towards determining if they can do radiation treatment. They are still awaiting data from Austin.
Tuesday 26-Aug-2008:
Muga scan. This is the scan that can give ideas as to how strong the heart is... specifically, they are trying to make sure that the chemotherapy did not have adverse effect on the heart which would cause a delay or change in treatment... just being cautious and gathering more data for the final determination on how we will proceed with the surgery.
Monday 25-Aug-2008:
Kris met with Dr. Jones who was happy to note that the wound is finally healing! We have hopes that by the time it heals... well, we'll have had the port out and a new wound to heal in its place!
Tuesday 26-Aug-2008:
Muga scan. This is the scan that can give ideas as to how strong the heart is... specifically, they are trying to make sure that the chemotherapy did not have adverse effect on the heart which would cause a delay or change in treatment... just being cautious and gathering more data for the final determination on how we will proceed with the surgery.
Thursday, August 21, 2008
Kris, Dave and the Lumps: Chemo the last!
Tuesday 19-Aug-2008
Last infusion of Taxotere and Herceptin!
Saw a colleague of Dr. Moran. Seems Dr. Morans PA was out, Dr. Moran was on hospital duty and later we found out that another of his colleagues was out sick! She was very familiar with our case through the cancer conference! We'd heard early on that our case was going to be presented at such a gathering of Oncologists. What we didn't know was that they meet like this about once a month. On the one hand it's nice to hear that so many folks are reviewing your case. On the other, I can't help but wonder why our case gets so much attention. She suggested a change in our next appointment with Dr. Moran so that he would have time to hear the review from the conference before our appointment with him. The radiologist as well as our surgeon and reconstructive surgeon (read: plastic surgeon) all sit in on that conference too, so, we'll have a review where all of our Drs. are discussing our case.
She revealed that they only had the summary of the radiation films from the Round Rock Cancer Center from Kris' first bout with breast cancer. We needed to make sure that the full charts were forwarded. We signed another release form just to make sure that would not be an obstacle to getting the reports released from the Round Rock Cancer Center.
We then went on for the infusion and everything went smoothly. While we were doing that, I wandered off and rescheduled our appointment with Dr. Moran, scheduled the appointment with Dr. Antel (the Radiologist). His assistant revealed that he may well call and cancel if he's positive that we can't do radiation due to the previous treatment.
During the infusion we met a nice man I nick named 'stanley steamer' because he was carrying an oxygen machine around with him that would 'puff' every so often. He asked me if I was cheating to beat Kris at Cribbage... I assured him that I was not, despite the fact that it is pretty much the only way to beat her at the game!
When the infusion was done, we got a cup of kisses (Hershey's) and a certificate of completion signed by the whole staff... or at least those present! It's a nice touch we also got from the Round Rock Cancer Center.
Friday 17-Aug-2008
Met with Dr. Moran to review how things are going in preparation for Tuesdays infusion. Dr. Moran wants Kris to see a Radiologist to discuss the possibility of radiation treatment after surgery. We were given to understand that she's had her lifetime limit. This request personally makes me a little anxious that he doesn't believe we'll get a cure from the treatment we are going through. Kris is upset at the prospect of having a mastectomy with no reconstructive surgery until the radiation treatments are done.
He also wants Kris to get an MRI and a pet scan and to have those results before we see the Radiologist.
We made a point of showing him Kris' nails. They are discolored for the latter half of the bed (that's the red or pink part of the nail, attached to the finger). We were thinking this is a side effect of the Xeloda, but, it's apparently a known side effect of Taxotere. As for the Xeloda, Kris' hands are still just a tidge pink and her Acid Reflux is quite bad. Based on this, he decided that we'd not to Xeloda for this round... so, we are done with Xeloda! The down side is we have tons of the stuff left over... there's a pile of money down the tubes. It's not like we can give the drugs back for a refund and while the cost isn't huge for us, it is a cost somewhere and in the end we pay for these things by increased insurance rates (or companies dropping insurance). For the Acid Reflux, Dr. Moran suggested that we include Pepcid AC along with the Nexium. We'll give that a whirl.
Finally, before leaving we made appointments for the follow-up with Dr. Moran as well as the Pet and MRI scans.
Last infusion of Taxotere and Herceptin!
Saw a colleague of Dr. Moran. Seems Dr. Morans PA was out, Dr. Moran was on hospital duty and later we found out that another of his colleagues was out sick! She was very familiar with our case through the cancer conference! We'd heard early on that our case was going to be presented at such a gathering of Oncologists. What we didn't know was that they meet like this about once a month. On the one hand it's nice to hear that so many folks are reviewing your case. On the other, I can't help but wonder why our case gets so much attention. She suggested a change in our next appointment with Dr. Moran so that he would have time to hear the review from the conference before our appointment with him. The radiologist as well as our surgeon and reconstructive surgeon (read: plastic surgeon) all sit in on that conference too, so, we'll have a review where all of our Drs. are discussing our case.
She revealed that they only had the summary of the radiation films from the Round Rock Cancer Center from Kris' first bout with breast cancer. We needed to make sure that the full charts were forwarded. We signed another release form just to make sure that would not be an obstacle to getting the reports released from the Round Rock Cancer Center.
We then went on for the infusion and everything went smoothly. While we were doing that, I wandered off and rescheduled our appointment with Dr. Moran, scheduled the appointment with Dr. Antel (the Radiologist). His assistant revealed that he may well call and cancel if he's positive that we can't do radiation due to the previous treatment.
During the infusion we met a nice man I nick named 'stanley steamer' because he was carrying an oxygen machine around with him that would 'puff' every so often. He asked me if I was cheating to beat Kris at Cribbage... I assured him that I was not, despite the fact that it is pretty much the only way to beat her at the game!
When the infusion was done, we got a cup of kisses (Hershey's) and a certificate of completion signed by the whole staff... or at least those present! It's a nice touch we also got from the Round Rock Cancer Center.
Friday 17-Aug-2008
Met with Dr. Moran to review how things are going in preparation for Tuesdays infusion. Dr. Moran wants Kris to see a Radiologist to discuss the possibility of radiation treatment after surgery. We were given to understand that she's had her lifetime limit. This request personally makes me a little anxious that he doesn't believe we'll get a cure from the treatment we are going through. Kris is upset at the prospect of having a mastectomy with no reconstructive surgery until the radiation treatments are done.
He also wants Kris to get an MRI and a pet scan and to have those results before we see the Radiologist.
We made a point of showing him Kris' nails. They are discolored for the latter half of the bed (that's the red or pink part of the nail, attached to the finger). We were thinking this is a side effect of the Xeloda, but, it's apparently a known side effect of Taxotere. As for the Xeloda, Kris' hands are still just a tidge pink and her Acid Reflux is quite bad. Based on this, he decided that we'd not to Xeloda for this round... so, we are done with Xeloda! The down side is we have tons of the stuff left over... there's a pile of money down the tubes. It's not like we can give the drugs back for a refund and while the cost isn't huge for us, it is a cost somewhere and in the end we pay for these things by increased insurance rates (or companies dropping insurance). For the Acid Reflux, Dr. Moran suggested that we include Pepcid AC along with the Nexium. We'll give that a whirl.
Finally, before leaving we made appointments for the follow-up with Dr. Moran as well as the Pet and MRI scans.
Wednesday, August 13, 2008
Kris, Dave and the Lumps: Chemo #5, Week #2
13-Aug-2008
No news is indeed good news. We are waiting for the next round of appointments. Meanwhile, Kris is doing ok, but, still suffering the effects of Xeloda. This is by no means as bad as when she is taking the drug. Obviously it takes this stuff quite a while to get out of the system. Right now her hands are mostly ok but her acid reflux is not very good. Almost done... one more infusion to go!
No news is indeed good news. We are waiting for the next round of appointments. Meanwhile, Kris is doing ok, but, still suffering the effects of Xeloda. This is by no means as bad as when she is taking the drug. Obviously it takes this stuff quite a while to get out of the system. Right now her hands are mostly ok but her acid reflux is not very good. Almost done... one more infusion to go!
Wednesday, August 6, 2008
Kris, Dave and the Lumps: Chemo #5, Week #2
Monday, 4-Aug-2008:
Went to see Dr Kuisle, the plastic surgeon. Our impression from Dr Moran was that we would be able to do surgery middle or early of September. Dr Kuisle put the kabosh on that! We will be having surgery in Early October. This means that Kris will be out longer than 6 months which means she has to wade through the mountain of paper work for Long Term Disability (LTD form here on out).
Warning: anatomically correct stuff to follow, don't read this part if you are squeamish or don't want to read words that might offend the easily offended.
Dr Kuisle said that there will be an outpatient procedure first. This is to clip off some blood vessels that feed the tissue in her stomach that will be used to reconstruct her breast. Not to fear, these blood vessels are from below, there is another set from above. The set from above will be used to supply fresh blood (and remove blood which needs refreshing) from the new breast. The idea is that they want to strengthen the set from above and make sure that it's the primary source of blood for this tissue. There will also be subsequent surgeries to balance both breasts. You don't want one brand new perky breast and the other one either higher or lower so, he'll be adjusting the one to match the other... well, within the norm. Much like feet, both are almost never perfectly identical (part of what makes us unique, and special... and human).
Resume to the safe stuff:
We also saw Dr. Jones. He hemmed and hawed and basically said that things look good enough (in relation to the port wound which still hasn't closed). We told him about our visit with Dr. Kuisle and he said that he'd leave the port wound alone for Dr. Kuisle to deal with. We said that when he takes it out, Dr. Kuisle wouldn't be touching the right breast (where the port is... oops, sorry, one of those words popped in here) until it was time to match it to the reconstructed left one. This would be a while after the initial surgery. Based on that information, he said that he'd take the port out during the mastectomy and, I'm sorry I don't remember the word but basically he'd 'freshen' the wound so that it would heal normally after the surgery to remove the port.
Tuesday, 5-Aug-2008:
Ran errands today in pursuit of long term disability. What seems odd to us is that they want us to fill out LTD forms 3 months in advance to start LTD at the 6 month mark. Initially we weren't even sure the treatment would last 6 months or more so held off. Now that we are filling it out, we find out that we are required by Cigna to apply for Social Security LTD benefits... however, Social Security doesn't give benefits until a year out. Thus, Cigna is requiring that you pursue LTD 9 months before you can get it (from Social Security). Oy Vey!
Having said that, it does make some sense. Basically, to defray the cost of Long Term Disability, the insurance company requests any benefits you get from Social Security... then they just handle cutting you a check. Now, SS won't kick in until the year mark, so, the insurance agency will cover it fully until then.
Wednesday, 6-Aug-2008
Kris is fighting with the LTD paperwork. Amazing how frustrating, detailed and generaly ponderous this process is. They are asking for the names of the prescriptions she's on for her treatment, when each procedure (or at least many of her procedures) was performed. Then, 2 hours after starting the paperwork (online), the form disappeared... My take on this is that they really want to dissinsent folks from using this benefit. Did I mention that studies are investigating the relationship to stress and triple negative breast cancer (the kind Kris has). Ie: there is evidence that says stress helps the cancer to grow... seems criminal to have paperwork that is designed to be stressful for a patient of this disease, doesn't it?
Went to see Dr Kuisle, the plastic surgeon. Our impression from Dr Moran was that we would be able to do surgery middle or early of September. Dr Kuisle put the kabosh on that! We will be having surgery in Early October. This means that Kris will be out longer than 6 months which means she has to wade through the mountain of paper work for Long Term Disability (LTD form here on out).
Warning: anatomically correct stuff to follow, don't read this part if you are squeamish or don't want to read words that might offend the easily offended.
Dr Kuisle said that there will be an outpatient procedure first. This is to clip off some blood vessels that feed the tissue in her stomach that will be used to reconstruct her breast. Not to fear, these blood vessels are from below, there is another set from above. The set from above will be used to supply fresh blood (and remove blood which needs refreshing) from the new breast. The idea is that they want to strengthen the set from above and make sure that it's the primary source of blood for this tissue. There will also be subsequent surgeries to balance both breasts. You don't want one brand new perky breast and the other one either higher or lower so, he'll be adjusting the one to match the other... well, within the norm. Much like feet, both are almost never perfectly identical (part of what makes us unique, and special... and human).
Resume to the safe stuff:
We also saw Dr. Jones. He hemmed and hawed and basically said that things look good enough (in relation to the port wound which still hasn't closed). We told him about our visit with Dr. Kuisle and he said that he'd leave the port wound alone for Dr. Kuisle to deal with. We said that when he takes it out, Dr. Kuisle wouldn't be touching the right breast (where the port is... oops, sorry, one of those words popped in here) until it was time to match it to the reconstructed left one. This would be a while after the initial surgery. Based on that information, he said that he'd take the port out during the mastectomy and, I'm sorry I don't remember the word but basically he'd 'freshen' the wound so that it would heal normally after the surgery to remove the port.
Tuesday, 5-Aug-2008:
Ran errands today in pursuit of long term disability. What seems odd to us is that they want us to fill out LTD forms 3 months in advance to start LTD at the 6 month mark. Initially we weren't even sure the treatment would last 6 months or more so held off. Now that we are filling it out, we find out that we are required by Cigna to apply for Social Security LTD benefits... however, Social Security doesn't give benefits until a year out. Thus, Cigna is requiring that you pursue LTD 9 months before you can get it (from Social Security). Oy Vey!
Having said that, it does make some sense. Basically, to defray the cost of Long Term Disability, the insurance company requests any benefits you get from Social Security... then they just handle cutting you a check. Now, SS won't kick in until the year mark, so, the insurance agency will cover it fully until then.
Wednesday, 6-Aug-2008
Kris is fighting with the LTD paperwork. Amazing how frustrating, detailed and generaly ponderous this process is. They are asking for the names of the prescriptions she's on for her treatment, when each procedure (or at least many of her procedures) was performed. Then, 2 hours after starting the paperwork (online), the form disappeared... My take on this is that they really want to dissinsent folks from using this benefit. Did I mention that studies are investigating the relationship to stress and triple negative breast cancer (the kind Kris has). Ie: there is evidence that says stress helps the cancer to grow... seems criminal to have paperwork that is designed to be stressful for a patient of this disease, doesn't it?
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