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Caregiver to a stage IV Renal Cell Carcinoma Cancer Patient

jshorty29's picture
jshorty29
Posts: 12
Joined: Apr 2014

Greetings friends,

On December 31, 2013, my husband was diagnosed with stage IV Renal Cell Carcinoma.  We are devestated beyond belief.

 

My question is:  As his caregiver, can you provide me with suggestions on how to help him?  Aside from handling all the logistics...medical insurance, appointments, research, meds, and of course all the necessary things pertaining to his health...healthy meals, juicing, massage...what more can I be doing for him?  This is all very new and it's so incredibly hard to see my once strong, healthy man so tired, weak and thin.  Emotionally, I'm not sure what to always tell him or how to comfort him.  We are doing our best to stay positive but when the bad days hit, I'm at a loss for words.  I've suggested he try attending a support group. 

 

I guess what I'm looking for is suggestions or words of wisdom from others who are in my situation.

 

Love and light,

 

 

Jen

cubsfan9
Posts: 43
Joined: Oct 2013

Good Morning, Jen!

Welcome to this exclusive club...one none of us would have chosen to join!! 

I am sorry to hear about your husband.  All of us on this board are in the same situation...some as caregivers, some as patients.  It is a good place to ask questions, share information, and to vent!  Being a caregiver to a husband with RCC is a challenge.  You need to be and do all of the things you listed in your post, but don't forget you are first and foremost still his wife.  It is a learning process.  Some days you will get it right, others not so much.  I know one area I failed in early on was letting my husband do things for himself--including making decisions.  I came to realize that this diagnosis and all that went with it made him feel as if everything in his life was out of his control, and for a while he was more than willing to let others "do" for him as he came to grips emotionally with his illness.  However, it wasn't healthy for either of us.  From our experience I can say that there will be both good and bad days.  It is OK to have the down days...just don't dwell on them.  Pick yourself up, dust yourself off, and start being positive all over again. 

You didn't share whether your husband has had surgery or is receiving any treatments.  If you are willing to share some of that information others may chime in and offer suggestions.  Another great resource is smartpatients.com - there is a specific tag for caregivers that you might find helpful.

I am glad you are reaching out for support here and I am sure you will receive encouragement.    ~Sharon

Jojo61's picture
Jojo61
Posts: 407
Joined: Oct 2013

Hi Jen,

Welcome to our forum. You have come to the right place. You will find lots of good information, advice and support. I know that you will soon get a response from someone in a similar situation to yours.

I am a survivor, not a caregiver. My best advice is to be supportive in the health care, help in keeping track of things, nutrition, etc. The emotional part is a tough one. It depends on what your husband is like. Don't be afraid to share your own thoughts with him. That will alleviate second guessing. Just being there for him speaks volumes to him! Love and support is a combination that can't be beat!

He could attend a support group, it might be helpful to him. You might need something like that too. Don't forget to take care of yourself as well.

It sounds like you are already doing all the right things! Wishing you good health!

Keep us posted!

Hugs and smiles,

Jojo

Jojo61's picture
Jojo61
Posts: 407
Joined: Oct 2013

I just read your bio after I posted to you.

Jenn, I am not a medical guru member, but I do know that a lot of our members with advanced stage RCC have used many effective meds that have helped them. Chemo is never one of them. In fact RCC does not respond well to traditional chemo treatments. In your bio, you mention that your husband is on round 3 of chemo treatment. Those more experienced CSN members out there, please let's hear from you! What type of oncologist is your husband seeing? Whereabouts are you from? He should see an oncologist who is primarily focused on kidney cancer, as kidney cancer is a tricky one! More info will be needed, Jenn.

Hugs and smiles,

Jojo

sblairc's picture
sblairc
Posts: 141
Joined: Feb 2014

Well, one thing is for sure everyone's experience is slightly different but we are all united in supporting one another through this horrible disease. WELCOME.  There are several caretakers that post here, I'm newer. My experiences with the physical aspects of the disease so far have luckily been limited to a 2 hour ER visit that ended in a cancer diagnosis, a 9 day hospital stay and several weeks post nephrectomy recovery. Mentally, it is an ongoing battle for me and my husband as well.

One thing I learned (which my husband and I have subsequently discussed at length) is that immersing yourself 24/7 in the caretaking is unhealthy for your soul. We did the math: 236 hours straight spent together at one point. We agreed that if the cancer comes back, it can't be that way again. Our life together is never going to come to a complete halt the way it did the first time with the abrupt cancer diagnosis.  It wasn't healthy for our daughter to spend so much time without her mom, let alone see her dad in the hospital and have to move in with her grandma for 10 days. 

 

I still see a therapist because I struggle with anxiety about cancer recurrence. My husband is considered "high risk" for it to come back. I deal with this now by talking to a therapist. I try to acheive balance between keeping him updated on current research and information I learn here without driving him crazy. He asked me last night to back off on the "cancer talk" since his scans are coming up. I guess open communication between one another has been very helpful but therapy was really what helped me deal. 

Interestingly enough, he recently told me that our marriage is better since he had cancer. It wasn't in a bad place before, but I certianly know what he means. When you love someone so much and go through cancer together, I think it changes you forever. Luckily in our case, it evidently changes us for the better. Please come here often and look for support if you need to. You will find it here. 

NanoSecond's picture
NanoSecond
Posts: 547
Joined: Oct 2012

Hi Jen. I am sorry to hear what you and your husband are going through.

But would it be possible for you to provide some more specific information about your husbands RCC?  Because, in general, traditional chemotherapy is not appropriate for treating most kinds of renal cancer.

Could you provide his cell histology (i.e. clear cell; chromophobe; papillary; etc.) and exactly what "chemo" drugs he is taking?  That way some of us might better comment on how best to proceed.

One other suggestion.  Please register at:  www.SmartPatients.com

That website is made up of patients and caregivers (just like this site) but will provide you with much more in-depth information and personal experiences.  If your husband has a very aggressive form of RCC that does respond to traditional chemotherapy you will find many others over there who are following similar regimes.

Hang in there.

jshorty29's picture
jshorty29
Posts: 12
Joined: Apr 2014

Wow!  What an amazing sourse of support and a plethera of information!  Thank you!

To provide a bit of medical information, David was just recently diagnosed New Year's Eve and began taking Sutent on January 1st.  At that time, David's only medical insurance was Veterans Insurance.  We spent 7 days at the VA in Long Beach, CA.  We met with his Oncologist no more than 5 minutes and we're given an RX for Sutent.  Within the first cycle, I began researching and discovered chemo (Sutent) is the "norm" the "gold standard" in treating RCC, BUT after further research, I discovered that it is only effective on about 15% of RCC patients.  We immediately sought a second opinion and payed out of pocket for a well known educator and Oncologist at UCI who confirmed the diagnosis and proceded to inform us that he would also prescribe Sutent (2 rounds only) and then look at other options that might "prolong" David's life.  David was given the grim prognosis of 20 months.

This week, we FINALLY have another PET/CT Scan to see if anything has changed.  His first scan showed a golf ball size mass on his left kidney, "growths" in his neck, trachea, spleen and stomach lining.  Nano Second:  I'm embarrassed to say, I have no idea what his cell history is...the two times we met with his oncologist at the VA, nothing like this was ever mentioned to us.

On a good note, however, I was also able to get health insurance for David and we have moved over to UCI and away from the VA hospital, where the oncologist admitted they weren't able to help with clinical trials and such. Such a sad way to treat our vets!

This is all still very new for us and we feel overwhelmed with all of this.  I think once we receive the findings on this next PET/CT Scan and meet with our new Oncologist at UCI, we will have a better understanding of what, if anything, we can do next.

I hope this brief overview gives you a better understanding of where we are at.  We have two small children at home, one with special needs and I'm overwhelmed with trying to figure out what to do next, how to keep everything at home as normal as possible and to make sure our boys are not picking up on the tension and fear that sometimes penetrates our walls. 

Also, thank you for the smart patients website,  I'm jumping on there next to see what I can find.

I'm wishing all of you a gentle and restful night.

 

Love & light,

 

Jen

 

Darron's picture
Darron
Posts: 224
Joined: Jun 2013

Welcome to the group, sorry you are here. Take heart in the fact that you are not alone. Tap on my bio for a moment and spare me typing on my phone. I am a stage IV patient, diagnosed in Oct 2012 with a 15cm 2lb tumor in my right kidney, a 3.4 cm tumor in my adrenal gland, And several lung mets. I atarted a drug trial of Sutent and Nivolumab in Feb. 2013. I appeared to be cancer free in Jan 2 2014, but have since had a scan that showed a new lung met. 

Be aggressive with questions when you meet your new oncologist. Ask how he /she plans to extend your husband's life indefinitely. My first meeting was a blur and I was extremely confused and emotionally a wreck. It kept me from asking good questions. weite down your questions ahead if time and don't leave until you understand the answers.

there are multie drugs like Sutent that are designored to inhibit tumor growth. Dutent is one of 7 my dr discussed. Immunotherapy is a newwe approach and appears to have curative potential. The oldest immunotherapy is a drug called IL-2,but there is a new araenal of drugs going thru trials now called anti PD-1 drugs. They give all us stage IV folks reason to have hope that a cure is near.

a positive attitude goes a long way. I may well die from kidney cancer, but I don't think it will be today, so I choose to make the most of today. Sutent has a higher response rate that you quote. It will most likely sheink the tumors and hold the cancer at bay for some time. Believe that... If scans don't slow that, there are other drugs that can do the same. It sometimes takes a while to find the right drug for each of us. We panic when one doesn't work, but that is normal....you then try the next one and pray it works.

Hanf in there, there is hope. Ask wheat other drugs your oncologist will try if Sutent doesn't show benefit. If he doesn't have a plan, find a new RCC specialist.

Be well you are in my prayers.

NanoSecond's picture
NanoSecond
Posts: 547
Joined: Oct 2012

Hi Jen.  Thanks for the additional information.  Sutent is a perfectly appropriate therapy to begin with.  However, it is not considered "traditional" chemotherapy (although technically, of course, it is).  Sutent is one of several effective TKI's (Tyrosine Kinase Inhibitors) that work to interfere with the molecular signals that tumors secrete to stimulate the formation of their own "private" blood vessels.  They need these additional blood vessels to grow and proliferate - so if Sutent or another TKI can inhibit these signals the tumor will stop growing and, in many cases, start to shrink.  However, these drugs are not a "cure".  The strategy for using them is that they can be a "delaying tactic" that one can employ to extend one's life while, hopefully, waiting for newer drugs that will offer long-term remission. 

One class of such drugs are called immunotherapies.  They rely on one's own immune system to do the "heavy lifting" - that is, to fight and kill the tumor cells.  If the immune system can recognize tumors as "alien" they will attack and eliminate them.  Unfortunately, most tumors are rather clever and they have numerous mechanisms that allow them to appear as normal cells to the immune system.  In which case the immune system will just ignore them.  The oldest effective immune therapy, mentioned earlier, is called HD IL2 (High Dose Interleukin-2).  It is FDA approved. About 7-14% of the clear cell patients who undergo this therapy achieve the holy grail of a Complete Response (CR).  Others get a Partial Response (PR) whereas others get no response at all.

The newer immune therapies are mostly confined to clinical trials right now.  One of the most promising is to block the PD1/PDL1 pathway.  PD means "Programmed Death".  These drugs are known as "Checkpoint Inhibitors" or, more commonly as anti-PD1 or anti-PDL1. But once again, only a small minoritiy of patients (so far) are achieving CR with them.  Still, it is a very benign treatment (not like HD IL2 which requires hospital supervision and is a very tough regime to undergo).  Hopes are high that that combining PD1/PDL1 with other treatments will likely expand the base of Complete Responders.

angec's picture
angec
Posts: 626
Joined: Mar 2012

Hi Jen, nice to meet you!  First, let me say that I am sorry for all you are going through! I think you are doing a remarkable job handling all on your plate! Your family are blessed to have you!  I had a pre-emie also. He was 28 weeks, ten years old now.  I have an idea of what you are dealing with there.  

 

How do they know it is RCC? I am assuming that you have no path report to know what type of cancer your husband has. I may be wrong, but did he have surgery? From what you wrote he didn't have surgery yet and they are still figuring out what to do.  When he does have surgery to remove the Kidney, then get the path report as soon as possible. Get a copy of all of his reports, blood work etc. for each and every test he takes.  Keep them in a file.  If possible, also get the scans on cd rom and shuffle that along with you to any doctors you go to for a second or even third opinion. The mere fact that they told your husband he only has 20 months puts out a signal to me.  It signals to me that maybe he isn't with an "up to date" doctor.  Most doctors today that are experienced with Kidney cancer will not say those words.  They know there are drugs out there that can kick cancer's you know what! Since your husband is young, he might be able to try the IL-2 which Nanosecond spoke about. Please ask them about this. He will test to see if he can do it.  There are also other immunotherapy drugs trials that were mentioned.  Please correct me if he did have surgery already.

So, in short I would like to tell you that you go forward believing that your husband can be treated and be stable.  You stay on these boards and work with us here and we will help you to be sure you do all the necessary things.  I hope by now you signed up with www.smartpatients.com.  There are a lot of VERY educated people there with lots of experience, both as patients, and in the medical field as well. You have a family here, now.  

I was going to suggest, if at all possible, that your husband join the group here.  I am guessing you are sharing the posts here with him, and he is happy to note that others here had been told they should have passed on but are flourishing.  

You be sure to take care of yourself as well. Take time to meditate and eat and sleep as much as you can.  Anytime you need a shoulder, come here and you will also get virtual hugs along with it!  Many prayers are going out for you.  You can do this!  XXOO  Keep in touch!

Angela

cran1's picture
cran1
Posts: 128
Joined: Mar 2013

Hey Jen you and your husband are in my thoughts. Hang in there. 

foxhd's picture
foxhd
Posts: 1951
Joined: Oct 2011

First of all I like what Darron said. Ask your Dr. directly what he/she intends to do to extend your husbands life. You'll find out in a minute if he/she is the right doctor for you. Second, All is not lost. Be a bit pushey to get the right doctor. This forum is loaded top to bottom with people who moved on to another doctor after being treated by their first or second oncologist. It is easy to believe that all oncologists should be equal. That is the biggest misconception. Especially with kidney cancer. You will be surprised how many have had their pc or urologist tell them they could handle their cancer and they don't need a specialist. Very scarey. Read this forum.

Second, most of us are doing very well after finding the right oncologist. You need to know that I was expected to die by spring 2012. But today I am fit, strong, happy, and thankful. I am more than 90% cancer free. What's left is stable and controlled. I have a long life expectancy now.

You need to get more details about your husbands cancer. Request as many records as you can get. It's all confusing now. But you'll become a kidney cancer genius pretty quick. Good luck.

danbren2's picture
danbren2
Posts: 191
Joined: May 2013

Jen,

     Even though things may seem a bit overwhelming right now you have come to a place with good information and even better support.  When I first came here I had my questions answered right away or was told where to go to get an answer.  You are never alone here, we get mad, we cry, we ask why, and we even laugh, but most important we no longer feel alone.  I am wishing for the best for your husband and for continued strengh for you!

                                          Brenda

jshorty29's picture
jshorty29
Posts: 12
Joined: Apr 2014

I'm sure I'm extremely emotional these days, but I can't help but be moved to tears with all of your responses and VERY USEFUL information. Feeling blessed I found this site and all of you.  Thank you for your responses.

David has an appointment tomorrow with his new Oncologist at UCI and I am taking your words, suggestions and valuable information with me.  We are forming a game plan and we are now feeling better equipped to take charge of David's medical course of action.

I'll provide you with an update once we meet with the Oncologist and following David's PET/CT Scan once we receive the results and if ya'll don't mind, I might want to email you with additional questions...

Much love and light to all of you and may you enjoy the beauty of today.

 

Jen

 

 

 

GSRon's picture
GSRon
Posts: 1306
Joined: Jan 2013

Jen, write down your questions before hand, then take notes...  it will likely be fast paced, do not hesitate to act the doctor to slow down or repeat something.  Ask how many Kidney Cancer patients they have seen this year..  heck ask how many KIDNEY Cancer patients they see each day..! if the number is low... then you know what  you need to do...

Good Luck..

Ron

angec's picture
angec
Posts: 626
Joined: Mar 2012

 Just a side note to you Fox. You see the picture? Another motorcycle driver... wondering what they put in that fuel! ;)

todd121
Posts: 612
Joined: Dec 2012

Hi Jen,

I live in the same area as you and had a Stage 3 RCC tumor removed last year at UCI by Dr. Landman, head of the urology department at UCI. There are a couple of good oncologists at UCI with some RCC experience, but to my knowledge there aren't "RCC experts" at UCI. Unless there's somebody new or somebody I overlooked. Would you mind sharing the doctor's name? Is he/she a medical oncologist?

The RCC experts in the area are Dr. Figlin at Cedars Sinai (he's a top-notch, national RCC expert), Dr. Pal at City of Hope, Dr. Quinn at USC. There are some at UCLA also, but I don't know their names. These three doctors are kidney cancer oncologists that do research and follow lots of patients that have RCC. These are probably people your docs at UCI may call to consult.

There are some great doctors at UCI. I chose to move to City of Hope even though I live south of UCI because there were no RCC clinical trials at UCI. They were all in LA at Cedars under Dr. Figlin, or at City of Hope under Dr. Pal (or over at USC/UCLA).

If you're happy with your doctor, I'm not suggesting you change. However, if you want a second opinion, I recommend Dr. Pal at City of Hope (or the other two above). They live and breathe RCC and are really up on the clinical trials and what's happening in this field.

Best wishes to you.

Todd

 

brea588
Posts: 116
Joined: Jul 2012

Lifting you and your family up in prayers.  So sorry for all you are going through. I certainly will pray for you every night.

sblairc's picture
sblairc
Posts: 141
Joined: Feb 2014

Just letting you know I was thinking of you today. I hope you had a productive conversation with your husband's new doctors. 

a_oaklee
Posts: 174
Joined: Nov 2013

Hi Jen.  Welcome.  I'm sorry to hear about what you are going through and I can completely relate to your situation with your husband.  My husband was also diagnosed at a Stage 4 over 2 years ago.  It's probably a bit weird to say things calm down a little in time, but I have found it to be true.  The initial trauma of finding out about cancer is the worst.  Not to mention hearing that it's Stage 4.  We thought at the time that we were doomed.  But it's been over 2 years now and my husband is doing pretty well, considering.   This website has helped me immensely.  I got to read about other people who are Stage 4 and doing well for years and enjoying life.  It gives us hope.  You asked what more you can do for your husband.  It sounds to me like you have everything covered and that you are doing an excellent job of helping him.  Please remember to take care of yourself too.  I just can't think of what more you can do to help him, because everyone is an individual.  Hopefully you both just keep communicating to eachother how you feel and what you need.  You can send me a private email if you would like.  Take care.  Thoughts and prayers go out to you, your husband and children.

Annie 

Do you think your husband would enjoy participating on this site?  There are a great bunch of guys on here and I think it would be tremendously helpful.  My husband does not participate here.  I wish he would, but he's not big into being online, or opening up to others.  He relies on me to do research and only tell him positive uplifting stories. 

 

Jojo61's picture
Jojo61
Posts: 407
Joined: Oct 2013

Jen - just wondering how your husband's appointment went at the oncologist the other day?

Thinking about you.

Hugs and smiles,

Jojo

Txgrl
Posts: 24
Joined: Apr 2014

My dad had kidney removed in 1990 and it came back 23 years later. Multiple lesions in the spine, mass in the right surgery bed. It's hard to see my dad so weak. Dr diagnosed him having sciatica for the last three months. When they finally decided to run a CT scan they found it. Oncologist told my dad to go to hospice. I am not giving up that easy. He still has lots of life in him. The pathology report they could not determine the type of cancer. They assumed it was RCC since he had it before.

jshorty29's picture
jshorty29
Posts: 12
Joined: Apr 2014

Hello dear family (as I am now calling you)!

Thank you,  THANK YOU, for reaching out to me, via messages and this board.  So much has happend and it still seems like we are getting our ducks in a row, but definitely making progress.

As I had mentioned previously,  David is a vet and we were being seen at the VA in Long Beach...where all vets jokingly and with reason say, "this is where all vets come to die." David's oncologist is very green, a resident who couldn't seem to answer our questions.  I'm learning to become a bit of a pitbull with David's doctors.  This is MY husband, the father of MY children and we are now learning how to fight for his health...fight for our family.  David had a PET scan and David's urologist bascially said, the Sutent was a wash...his exact words were, "some things shrunk and others didn't...the tumor on his kidney actually grew."  Therefore, he considers it a "wash."  He also stated that he hadn't received the official reading from the radiologist yet so our oncologist would go over everything with us as soon as she gets the information.  He also said at this time, they would be looking into seeing if removing David's affected kidney would be the next course of action.  He also mentioned, the VA does not do IL-2 and they have to apply for clinical trials, and it is a VERY slow process being that the VA is a government funded hospital.

With all of this being said, I immediately switched our care to UCI and our oncologist is now Dr. Fruhauf, who we feel VERY comfortable with.  Not only did he answer all our questions, but he went over options with us.  He is well known in his field, an educator and it was like speaking to a true Jedi Knight as opposed to a mere padawan (only Star Wars geeks like myself with get this). ;) He reviewed David's medical records from the VA and he is just waiting to review the PET scan.  He talked about IL-2 (which ya'll have been mentioning) and PD-1, which will be approved for Melanoma in June at UCI and as he mentioned, he can find ways to get David approved for whatever trials he can.   Because of David's age and his strength, Dr. Fruhauf feels David will be a good candidate.  We have a meeting with him next week, once he reviews the PET scan and David's medical history, we will come up with a plan of attack. 

I hope we are now on the right course.  David is feeling quite low right now after hearing what the VA urologist mentioned. But, now at least we have someone in our corner who I feel will guide us in the right direction.  I'm asking David to remain hopeful, even when the odds are stacked against us.  I know he is fearful because the thought of leaving our two babies, ages 3 and 22 months scares him more than anything else.  We are definitely trying to find our balance and I know it's so much harder for David.  I've also gently mentioned that he might want to meet other cancer patients /survivors who understand what he is going through, who can help encourage him when he needs it.  I also mentioned this site and I am hoping he joins.  I have received more information, encouragement and understanding than I ever thought possible and this site is helping me to hold on.  I'm hoping Dave will decide to reach out as well.  Also, I'm not sure who is on FB here, but I created a FB page called A Warriors Battle if you would like to check it out and possibly encourage him there. :)

https://www.facebook.com/davidsfight47

Ok, with all this being said, am I missing anything?  Is there more I can be doing?  Angela, thank you for your words of encouragement and to all of you, thank you.

I will be in touch as we move forward. 

Love & light,

 

Jenny

 

 

cubsfan9
Posts: 43
Joined: Oct 2013

Good Morning, Jenny!

I am so glad that you have changed doctors and have found someone who knows about RCC and with whom you feel more comfortable.  I am not usually  one to be critical, but the first urologist knew less than you about his disease!!!  And, yes, being a pit bull is a good thing.  When we were just starting our journey we were having a problem with the mail order drug company that provides the Sutent.  I was still too much of a newbie and too emotional to deal with them, but there was a nurse in the oncol office who got on the phone and got action and got it fast.  We called her 'the pit bull' at the time:)   She said she thinks of each patient as if they were her brother/sister/parent and wants them to receive the same care she would want for her family members.  As a result of what I have learned on this site and smartpatients.com I have become more of an advocate for my husband and am less fearful of speaking up when it is necessary.

Best wishes as you meet again next week and determine what the treatment plan will be.    ~Sharon

 

jshorty29's picture
jshorty29
Posts: 12
Joined: Apr 2014

Hi Sharon,

Perfect word, advocate. That's exactly what we are. :) Yes, the urologist really didn't provide us with much of anything and it was a frustrating visit as it left David depressed. Frustrating! But that visit also helped me find my voice. We are not giving up without a fight! 

Praying for you & your family. Much love & light!

Jan4you's picture
Jan4you
Posts: 201
Joined: Oct 2013

Hugs to you and yours, Jen  (((( HUGS )))

Sorry for ALL you and your darling hubby are going through. Glad you are being directed to better care. LISTEN and TRUST that inner voice to lead you both.  I can already tell you are~

I am glad you came here. There are so many who will offer you education, information and hopeful support!! You won't walk this journey alone.

Just wanted to let you know I too am thinking of you all!!

Warmly, Jan

sblairc's picture
sblairc
Posts: 141
Joined: Feb 2014

I'm SO glad to hear that your new doctor has such a pro-active plan in place. I am keeping your husband in my thoughts. I looked at your FB page, what beautiful kids you have. Wishing you strength while moving forward!

Jojo61's picture
Jojo61
Posts: 407
Joined: Oct 2013

with the switch of doctors, reaching out here, encouraging your husband to do so also. Keep us posted and stay strong! You are the kind of "pitbull" I would want on my team!

I will check out your facebook site.

Big hugs and smiles,

Jojo

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