More tests and trials

So last week I went to see the cardio-oncologist to get the results of my various heart tests. I was scheduled to have an echo test in the morning and then see the cardio-oncologist in the afternoon. I received a call from a research nurse asking me if I'd be interested in participating in a trial, to which I agreed (I'm always keen to contribute to medical science, as I am benefiting from it so much right now!). They were conducting a trial to see what type of heart test is the best type to use with cancer patients, so they wanted me to undergo a different type of test immediately before my echo test, and then they would compare the results. The trial test was an MRI heart test, where I had to lie in an MRI machine and hold my breath several times while the machine did its thing. Then I had my echo as expected, and then saw the cardio-oncologist. All the tests so far (including the heart monitor) show nothing out of the ordinary, so they are puzzled about my symptoms. They are going to investigate further, fitting me with a heart monitor for a whole week once I've had my next chemo, and they want me to come back and ride an exercise bike while hooked up to a heart monitor. Once again, I love the NHS for being so thorough, and it's good to hear that it doesn't seem to be cause for alarm.

Then today I had my pre-surgery tests: a mammogram, an ultrasound and an MRI. I'll discuss the results with my surgeon on 22 September when we'll plan my surgery. I've described these tests before so won't go into too much detail, except to remark on something. For the MRI I had to have a cannula inserted into the inside of my elbow so that they could inject the contrast dye during the testing, and they always flush a cannula with saline once it's in, just to test it. And the weird thing is, as soon as they inject the saline into my vein, I can taste it in my mouth! Isn't that strange? Fun fact.

So although I won't get the results from these tests for a while, the doctor who did my ultrasound told me the dimensions of my remaining cancerous lump, and it's 15% of its original size! And I still have one final chemo to go. So while the main purpose of chemo is to catch any stray cancer cells that have spread to other parts of the body, it's also shrunk my tumour to the point where surgery will be much less invasive than it would have been back in February.

Tanai drew the tumour sizes from my three ultrasounds, the original one, the half-way one and today's:

So tiny, I can no longer feel it. Here's to getting rid of it completely.

Heart scans and more tests

This week I had my 7th and penultimate chemo, and I'm now at home over a lovely sunny bank holiday weekend, recovering and trying to rest. My aunt Siobhan came down from Tunbridge Wells to join me in the hospital and she treated me to a relaxing hand and foot massage when we got back to the flat afterwards. I felt thoroughly pampered! It was so lovely to have a natter with her and catch up. An unexpected positive side effect of chemo. The other, not-so-positive side effects are kicking in now and I'm being gentle with myself, giving myself time to get well again. It's hard sometimes to look out of the window at the blue skies, hear the carefree laughter of passers by enjoying their summer long weekend, and not feel a little cheated by it all. But I know that this too shall pass, and I will have the opportunity to enjoy sunny long weekends again in the future. In the meantime I should rest, relax, heal and not be too hard on myself.

Since moving onto the new drug regime (which I've had for the last 3 rounds) I've been experiencing some heart palpitations which intensify about a week after treatment. I mentioned this to my oncologist on Monday so he has referred me to a cardio-oncologist to get my heart looked at. Although I have a Heart Echo test every 3 months to check that the Herceptin isn't having too strong an effect on my heart; as the nurse said at my last test, 'that's the plumbing, not the electrics'! So on Thursday morning I went back to St Bart's to have a 24-hour heart monitor attached. This consisted of three large circular patches, stuck to my chest and either side of my ribcage, which were each attached to some wires which then fed into a little box which clipped to my waistband. I had to wear it for 24 hours underneath my clothes and carry on as usual. I then popped back on Friday morning to take the kit back. Unfortunately (or fortunately, depending on how you look at it!) I didn't experience any major palpitations while I was wearing the kit. So we'll see what the results are. I have to head back into hospital on Tuesday afternoon for two different kinds of heart tests and to see the cardio-oncologist to assess the results. Once again, it's wonderful that the NHS are being so thorough at making sure I am okay: I feel as though I'm in safe hands.

Wearing my heart monitor

Today is quite a significant date, as it's exactly 6 months since Tanai and I were in a doctor's room and first heard the words 'you have a breast cancer'. I feel as though it's a milestone. Psychologically, perhaps in an attempt to contain what I'm going through, I have been thinking of this whole thing as 'pressing the pause button on life for a year'. I know it's much more complicated than that, but I want to ensure I don't feel bad about 'opting out' of things for a year while I go through treatment. It may take longer than a year, but at the moment that's how I'm looking at it. And I'm on track. So today is the half-way mark. From now on, I'm nearer to recovery than I am to diagnosis, and that feels good.

Only one more chemo to go! I know that a couple of months ago I never thought I'd get to this stage, so I feel very happy about this.

Siobhan enjoying the frittata and salad I made for our hospital picnic

Outside King George V building heading into chemo

Home to a relaxing foot massage

Collecting hair inspiration for when my hair starts to grow back

Potential trial participation

A little update from me just before I head into my 7th chemo session on Wednesday. All's well, my follow-up chest x-ray was all clear, there seem to be no concerns from my ECG and I'm ready to go for the penultimate round. It feels good to be close to the end of chemo. I've been invited to participate in a clinical trial so I thought I'd share the information with you as it sounds really interesting. Basically, there were some studies carried out into the beneficial effect of taking aspirin in those who had heart disease, and some of the data suggested that aspirin appeared to reduce the number of people who developed cancer, and if people did develop cancer, it appeared to be less likely to spread. So a huge clinical trial has been set up to test these theories, comprised of people who have been treated for cancer of the stomach, prostate, bowel, oesophagus and breast. They are aiming to recruit 3,100 patients who have been treated for early stage breast cancer, which is why they have approached me.

The trial is called the Add-Aspirin trial, and has already been running for over a year. It's funded by Cancer Research UK, the UK Department of Health and the Medical Research Council Clinical Trials Unit at UCL (University College London). They wish to test the long-term effects on the potential of cancer returning of taking a dose of aspirin every day. I will first of all have to take part in a 'run-in' period where I take a low dose of aspirin every day for 8 weeks. If all is fine, I will proceed to the trial. One third of participants will receive a regular dose of aspirin, one third will receive a low dose of aspirin, and one third will receive a placebo. I will not know which strand I'm in. They want me to take a tablet every day for 5 years. I will receive regular check-ups, blood tests, mammograms and other tests, as well as a questionnaire each year, because aspirin has also been alleged to protect against age-related cognitive impairment. (Hilarious! Can it help me remember my keys every day?)

One of the things I've been considering recently is how I can 'give back' after I complete treatment. I feel really positive about the opportunity to participate in something which could make a real difference to cancer treatment in the future, and potentially help save people's lives. Although I will be unlikely to personally benefit from this trial, there's a good chance that the data gained from the trial will benefit people in future. Plus, samples of my blood and a sample from my cancer (when they get round to removing it!) will be donated for research, which is pretty cool. I also like that I get an 8-week run to check that my body would have no adverse effects from taking aspirin. Plus, it's aspirin! People have been taking this for years. It's not as though it's some new drug that has only been tested on mice. So I think it's a pretty good thing to do. I'll let you know if I get on the trial.

Chemo 6, and the rollercoaster continues

This week was my 6th chemo session, leaving me with only 2 rounds left to go. It's somewhat strange as the majority of cancer patients I'm in touch with only have 6 chemo sessions in total, so here's where a lot of people get off the chemo train. But I get 2 extra doses of weedkiller so I'm not quite done yet. It's been an eventful few days, reminding me that this journey is never going to run smooth, but I'm doing okay, convalescing at home this weekend and waiting for the worst of the side effects to kick in.

On Monday I saw the oncologist as usual before my chemo session, to talk through how I am, and prepare anything different from the last time. I've seen three different oncologists from the team since my diagnosis, and for the last couple of rounds I've seen the head honcho guy, Prof. S___. He leads the team and is very distinguished in his field, having written heaps of papers and run lots of studies. He's a lovely chap with a friendly manner and a no-nonsense approach to what I'm going through. We discussed my little trip to A&E and I went through my notebook with all my new questions since last time (I write them down over the intervening weeks and go through them in my oncology session). We checked my bloods, and thanks to the GCSF injections my neutrophils were a healthy 5, so that was good. He then mentioned that he wasn't hugely happy about proceeding with chemo on Wednesday until I'd seen a dentist and could confirm 100% that I didn't have an abscess on my tooth. The risk is too great, apparently. So I left his office on Monday afternoon, having not registered with a dentist since returning from Australia, with a pretty hard deadline for getting my teeth checked out.

A cursory google and a few phonecalls later and I was booked into a dental clinic near the Barbican, near where I live, for the next morning. I had to shift some meetings around at work but I was so determined to avoid anything delaying my chemo schedule I became a little single-minded about it. Luckily, I hit the dentist jackpot. Not only is my new dentist lovely and efficient, she also happens to work in an NHS hospital as well as her private practice, and sees lots of cancer patients with teeth problems so completely knows her stuff. She had a thorough grounding of the impacts of chemo and radiotherapy on teeth, the key risks and things to look out for, and exactly what I should do in my situation. X-rays showed that I was abscess-free (yay!) so chemo could go ahead, but we have also come up with a plan for things we need to do between chemo and radiotherapy to ensure my teeth are impacted as little as possible by the effects of the rads. She has also prescribed me with high-fluoride toothpaste to protect my teeth from the effects of my cancer treatment, and she has given me a little blunt syringe so that I can get mouthwash into the niggling cracks around my wisdom tooth, to avoid an infection delaying chemo. I left feeling very happy and with a plan for October/November to ensure my teeth are also looked after through this.

Wednesday went ahead as planned, with my wonderful friend Caroline joining me on the chemo ward for a picnic lunch and a natter. I had the smiley nurses G___ and G___ again. Unfortunately, this was the first time they didn't get my cannula into a vein on the first go. It took 4 goes to find a vein as my poor little veins were collapsing, which was quite distressing (they ended up having to call the head nurse to do it!). I've been lucky so far and have had good veins, avoiding getting a PICC line fitted, but this time was tough, and I really hope my veins hold up to having 2 more rounds before I'm done. My hands are quite bruised now!

Selfie on the ward for chemo 6

As per last time I had quite a bit of energy (somewhat steroid-induced) for the couple of days following chemo, so I did some work and tried to keep busy. Then the rollercoaster came along again! I received a call on Thursday evening from my GP saying that UCLH had sent over a report following my visit to A&E and that they'd seen something a little worrying on my chest X-ray, so could I come in to see them. Friday morning I rock up at the GP and we go over how I am. She checked my breathing, asked me loads of questions about my heart, chest pain, the little flutter I've started to feel since shifting onto this new drug cocktail. She suspects that if the 'cluster' on the X-ray was the beginning of an infection, the antibiotics which I received at UCLH probably got rid of it, but she asked me to get another chest X-ray just in case. She also referred me for an ECG test (electrocardiogram) to check my heart is working as it should be. So I ended up spending most of Friday wandering round various hospitals of London (St Bart's and UCLH, because unfortunately the tests couldn't be done in the same hospital!) getting tests done. The results will be sent to my GP in the next few days, but hopefully it's not anything to worry about. To be honest, the main takeaway I had from all of this was a realisation of my GP's role in all of this. Each time I visit the oncology team, a letter gets typed up and sent to my GP, and of course they received the A&E report. Knowing that they are taking note of what's happening to me, and even called me when they thought something was awry, gives me great comfort as I go through this. Another example of our amazing NHS!

Display at UCLH of early anatomical drawings

This time around I have been given the GCSF injections in advance, so Tanai is administering a shot each day in my belly for the 3 days following chemo. Hopefully this should ensure that my neutrophils don't drop below the required levels and I can stick to my timeline. I've had my MRI booked in for early September, just before my last chemo, so that the surgeon has some up-to-date imagery to work from when planning my surgery, and I will meet with them before my last chemo. The light at the end of the chemo tunnel is finally visible, and I'm so ready to move onto the next stage of treatment: surgery. Chemo sucks, and I hope I never have to go through it again after all of this.

I now have my own sharps disposal unit for the used GCSF needles!

On Wednesday Tanai will go to Portugal, on the holiday we were supposed to be enjoying together, for his friend's wedding. I'll be sad to be without him for a week, and of course gutted that I miss out on a holiday and on meeting lots of his friends, but we have already started to plan some fun trips for next year, and soon we will have other holidays in the diary to look forward to. In the meantime, I have a host of friends who will hopefully swing by and see me during my week flying solo during treatment. Let's hope there's not another A&E visit next weekend!

A&E & Neutropenia

So, I guess it had to happen at some stage, and you could tell from my last post that I suspected the time would come soon. Yesterday we spent the whole day in A&E at UCLH (University College London Hospital, my nearest hospital with an A&E department, as St Bart's doesn't have an A&E).

I have been experiencing bone pain with the Docetaxel, including pain in my teeth and jaw, but over the last few days the pain has become concentrated on my lower left wisdom tooth, and my cheek and mouth has become swollen in that area. By Saturday evening the pain was intense, so I called the chemo hotline. The chemo hotline is a phone number I can call if I'm experiencing anything in a list of symptoms and I get through immediately to a nurse on my chemo ward. The number is attended 24/7 and they do encourage you to ring no matter how trivial you think the call to be, as they can help you decide what to do. Generally, the answer is 'Go to A&E!' but at least you feel as though it's legit.

I called again on Sunday morning and although the nurse was quite keen that I see a dentist to check out what was wrong, she was more concerned about the possibility of me being neutropenic, so advised I get myself down to A&E. Tanai and I headed over to Euston Square station and UCLH, and with my chemo platinum card I was fast-tracked through the people who had arrived at A&E on foot.

They did general observations, blood pressure, took a blood and urine sample, took jaw and chest x-rays and gave me my own room. I saw a doctor who advised that the x-rays came up okay, and I didn't seem to have an infection, but that I was indeed neutropenic. My neutrophils were 0.5 ('normal' is between 2 and 7, anything less than 1 is neutropenic) so they considered keeping me hospital in for observation. Meanwhile they gave me morphine for the pain and some intravenous antibiotics in case my tooth had an infection. They sent one of their oncologists to see me, a lovely woman called Dr O___, and she asked me lots of questions. She decided to give me my first G-CSF injection (granulocyte colony stimulating factor), which stimulates the production of white blood cells in the bone marrow. I received that and a 2-week course of antibiotics to take at home, and was discharged.

In my room at UCLH

Today I popped into St Bart's to see the team, and they have given me some codeine for the tooth pain (I do still need to see a dentist) and 5 more G-CSF injections for me to take at home, in order to try to build up my neutrophils so I can still have my next chemo on schedule on 2 August. So tonight, Tanai became a different kind of Dr to the one he's used to being, and injected me with my G-CSF. He was a bit nervous, and so was I! You have to pinch a bit of your belly and jab it sharply into the flesh, and then push the liquid in (it doesn't go in a vein). Neither of us really knew what we were doing but we googled it and then just went for it! But now we know how it's done, the next few should be relatively easy. I will now get these injections each time I have chemo, in order to boost my neuts for the next round.

Dr Cardona in the house!

As I'm neutropenic they have also advised me to be cautious and not expose myself to infection, so I'm working from home this week and trying to get as much sleep as possible, to allow my body the best chance to recover. I keep taking my temperature regularly and if it goes above 37.5 I will call the hotline. It's touch and go whether I will need to go back to A&E this week, but hopefully these injections and the antibiotics will do their job. I'm a little nervous that the tooth problem is significant, as it's generally not advised to have a tooth extracted during chemo (due to the risk of infection), but we'll see what the dentist says (if I ever manage to register with one and get an appointment!). All in all, not the most fun weekend I've had, but at least it wasn't too dramatic.

How do chemo drugs work?

I've been doing some research into the drugs I'm having administered in the hospital, and how they're each working to attack the cancer cells in my body. Having chemotherapy is a bit like finding some weeds under a beautiful rose bush, and deciding to spray hardcore weedkiller on the entire garden, just in case the seeds from these weeds have blown anywhere else. In other words, it's not always hugely targeted, but it can be very effective. Cancer cells (as with many other healthy cells) grow by going through what is called the cell cycle, in which a cell divides into two identical cells with their own set of DNA. Chemotherapy drugs interfere with various parts of this cycle so that the cells can't divide or repair themselves if damaged. Normal, non-cancerous cells have a better ability to repair themselves. There are over 20 different combinations of chemo drugs and the exact combo is down to the type of cancer you have, the most up to date research available and the experience and opinion of your oncology team. My cancer is ER+ (Oestrogen receptor positive), HER2+ (Human Epidermal Growth Factor Receptor 2 positive) and Progesterone + so I've been given the following regime of drugs.

The first four cycles I had were called AC, or Doxorubicin (A) and Cyclophosphomide (C). These are both first generation chemotherapy drugs, which mean they've been used for many years and are fairly standard. Doxorubicin (aka 'the red devil') is the red one I was given by hand in the syringe, and it's a type of chemo drug called an anthracycline. It slows or stops the growth of cancer cells by blocking an enzyme which they need to divide and grow. Cyclophosphomide belongs to a group of drugs called alkylating agents. It works by sticking to one of the cancer's DNA strands, which controls everything the cancer cell does. The cell cannot then divide into two new cells.

As we have seen, my 4 x AC cycles have been pretty effective, although I'm glad to see the back of the side effects on those drugs!

My next four cycles are TPH, or Taxotere (the brand name for Docetaxel), Pertuzumab (also called Perjeta) and Herceptin (the brand name for Trastuzumab). I've already had one cycle of this combo and will have three more. All of these are administered via a drip into the hand. The only one of these which is an actual chemotherapy drug is Docetaxel, which is nicknamed 'tax'. It's a third generation chemo drug, which means it's more effective than the first generation of chemo drugs, but brings with it an increased risk of infection. Docetaxel works by disrupting the microtubular network in cells, which is essential for cell division and other normal cellular functions. Docetaxel interferes with the function of microtubules, resulting in inactive microtubule bundles, causing cells to die.

Herceptin and Pertuzumab are actually not chemo drugs, they are monoclonal antibodies, but they are administered with chemo drugs because trials have shown that the effectiveness of both chemo drugs and monoclonal antibodies is dramatically increased if they are given together. Pertuzumab is a relatively recent drug to be licenced for use (December 2016) and at the moment it's only available if you have neo-adjuvant chemotherapy (ie chemo before rather than after surgery). Herceptin is also a relatively new drug and apparently there's a 2008 film called Living Proof starring Harry Connick Jr about Dr. Slamon's discovery of Herceptin. (Fun fact!) I will continue to receive Herceptin for a year through injections every 3 weeks, as well as these four cycles intravenously.

Both of these drugs are immune targeted therapies, which work by targeting specific proteins (receptors) on the surface of cells. Some cancers have too much of the protein HER2 on the surface of their cells (hence are HER2+). The extra HER2 receptors stimulate the cancer cells to divide and grow. Pertuzumab and Herceptin work by locking onto HER2 proteins. Each drug locks on to a different part of the protein. This blocks the receptors and stops the cells dividing and growing.

Here's a handy drawing from a book I have which shows how Herceptin works.

Also, here is a great animated video which really simply and clearly explains how monoclonal antibodies work.

It's incredible what advances in medical technology are being made every day, and I also know women who are taking part in medical trials for even more new drugs, each one potentially more effective than the last.

So I'm currently recouperating from the first TPH cycle which I had last week, and although there are lots of nasty side-effects from the AC which I'm thankfully not experiencing any more, instead they have been replaced by new ones! So no more nausea, constipation or fog-headedness, but hello bone pain, nosebleeds and chronic indigestion. I'm also having terrible sleepless nights which is not aiding my ability to heal. I'm feeling as though I'm operating on the final fumes of petrol in the tank, and I'm not sure where I will get the energy from for the last three rounds.

My neutrophils were incredibly low when I had my bloods done last Monday (they were 0.9 and they won't administer chemo unless they are at 1). Luckily they took my bloods again on the morning of chemo and they'd made it to the required level, but if you see this graph of my neutrophil counts that Tanai drew...

... if they carry on along this trajectory, it's looking unlikely that they will be at the required level by my next scheduled chemo, number 6. It's interesting to see how much they have reduced by each time. I'm trying to think if there's anything I did differently between rounds 4 and 5 which ensured they only reduced by 0.5, but all I can think of is our wonderful restorative weekend at Paddy and Lorraine's. Perhaps the extra relaxation helped! It certainly raised our spirits, so thanks for having us over.

Anyway, I know this post was rather dry and technical but if you got this far, well done for sticking with it, and I hope it was informative!

Stitching your parachute

My wonderful friend Dom accompanied me to my fourth round of chemo last month and while we were having a 5-hour natter about various things (we're both very good at talking!) he reminded me of the concept of 'stitching your parachute before you need it'. He couldn't remember if it was my advice in the first place or our mutual friend Caitlin's, but either way, it rang a bell for me and it's something I've been very aware of as I've researched the concept of resilience in light of my diagnosis. I suppose in very simple terms it refers to taking time to do the work of building your own personal and emotional resilience before you hit a crisis point. If you stitch up any holes in your parachute when you're happy and resting on the ground, it's ready for whenever you need it. If you leave it until you're in the tumbling aeroplane, it's too late, and it won't be adequate to save you.

As part of my own work looking after my mental health over the last few months, I've been pleased to discover that I'm already quite good at regularly stitching my parachute, and although I may not have had the vocabulary to describe it, self-care has always been something I've practiced. Whether it's something as simple as taking a Sunday evening bath, dropping some essential oils into the water and popping the Wittertainment podcast playing on my phone while I soak, or something as concerted as signing up to the Headspace app and resolving to practice 20 minutes of mindfulness each day, I've always taken time out for myself. I find walking incredibly restorative for my mental health, and would often walk the hour to and from work, pacing briskly and listening to a podcast or audio book, enjoying the changing seasons over the weeks. Cooking is another way I wind down and I usually cook my meals from scratch, enjoying the time it takes to prepare food, the creativity involved and the delicious rewards at the end. I often take myself round museums and galleries on my own, and enjoy 'me time' amongst the art or stories from other times and peoples. All these things are little ways over the years I've practiced self-care, taken some time for myself and shored up my mental health reserves.

Being resilient is not about being hard and impervious to the knocks and stresses life places upon you. It's about being flexible and able to cope in the face of adversity, to draw on internal strengths and those of the networks you've built around you. It means that when you suffer stress or trauma, you have the ability to adapt, to bend and stretch in the face of it, and to somewhat 'bounce back'. Importantly, however, it's not about being hard or unfeeling, or trying not to be affected by life's events; it's more about allowing the stress or trauma to take you in an unexpected new direction and allowing yourself to go with it, and not try to force your life, or yourself, to be a certain way.

With wonderful serendipity, just after my diagnosis my employer teamed up with the mental health charity, Mind, and decided to roll out some Emotional Resilience training for all staff in the organisation. We had an interesting presentation and were given time to think about what was in our 'resilience toolbox'. We discussed the pillars of resilience, and how we can cultivate emotional resilience in our lives and more effectively manage stress. There were some really useful tips in the presentation and it definitely made me think about this whole thing in a different way. Interestingly, it advocated writing as a way to step back from negative thoughts and get some distance. The presentation summarised the five ways to wellbeing thus:

Give: your time, your words, your presence
Keep learning: embrace new experiences, see opportunities, surprise yourself
Be active: do what you can, enjoy what you do, move your mood
Connect: talk and listen, be there, feel connected
Take notice: remember the simple things that give you joy

I think these are all small things that can contribute to positive mental health, and a stock of resilience for when life gets touch. They are great ways of stitching up one's parachute in preparation.

Another thing I've started to read about is post-traumatic growth, and positive psychology. These are theories about things you can put in place to ensure you grow from adversity, rather than being beaten down by it and suffering post-traumatic stress disorder. The theories acknowledge that post-traumatic stress is inevitable, following something as traumatic as a cancer diagnosis, but that there are measures we can put in place to deal with this stress, to go with it, and to emerge at the end with increased strength, wellbeing, and a practical pathway to positive change. It all sounds rather pop-psych but I do think there's some truth in it all, and I'm interested in reading more. One book I read summarised five dimensions of post-traumatic growth:

Recognise and use personal strengths
Nurture closer relationships
Enjoy a greater appreciation of life
Search out and embrace new possibilities
Deepen spiritual development

Again, all great advice, which according to Aristotle, can lead to a form of happiness called Eudaimonic wellbeing, which is particularly flourishing and fulfilled. Well, we'll see about that, at this stage I'm just grateful to be engaging in these thoughts, to continue to function at work and at home, and to cultivate hope and optimism while I'm going through this. With chemo side-effects robbing me of many of my usual forms of self-care (no energy to walk, changed tastebuds affecting my enjoyment of food, lack of sleep etc) it's taking most of my strength just to get through each day. I'll save the real rebuilding work until I'm done with active treatment.

A running theme through a lot of the things I've been reading around this topic is the importance of building strong networks around you. I've always had a huge capacity for friendship and have cultivated relationships with people all over the world throughout the years. This is undoubtedly a huge source of strength for me at the moment, as I receive messages, gifts, thoughtful cards and offers of assistance from many of you, my global team of cheerleaders as I navigate this particularly tricky time. Even when I have a wobble, you've got my back, so thanks everyone. You're the best tool in my resilience toolkit. (Naw!)