Infusion no. 2 and other diversions

I had a triple appointment yesterday (three and a half hours, with breaks): blood draw, then the oncologist, then infusion. The oncologist meeting is to go over the results of the blood draw and to discuss any side-effects I may be having. The levels of a certain enzyme associated with the liver are again high, even higher than they were before. As to side-effects, the concerns I expressed in previous posts were certainly overblown (I must sheepishly admit, baa baa). The most prominent of these is fatigue---more on this below---but there doesn't seem to be anything you can do about it. I've had some stomach upset too, but not too bad. Then you start wondering: gosh, I'm out of breath walking up this hill; is it the pembro or am I just out of shape? However, when I mentioned to the onc that I'd done a nine-mile Father's Day hike with Jessie, he kind of laughed and said he wouldn't worry about out-of-breathness.

The other new development is that I've been having various pains on the right side of the abdomen. My theory is that these are due to too much tossing the grandkids around and/or some of my blackberry hacking, both of which could stress rarely-used muscles. But since the right side is where the liver is, it seemed a good precaution to mention it to the onc. In particular, I've been having some weird pain in and around the right clavicle. The onc suggested two possible cancer-related explanations: First, the tumor in the liver could be pressing on the bottom of the diaphragm, which can cause pain---so-called ``referred pain''---in a completely different area such as the clavicle. Second is the worst-case scenario of cancer spreading to the bones. For that reason he wants me to have a bone scan.

Personally I think this is all a very expensive wild-goose chase; I'm guessing it's just some kind of muscle or ligament tear resulting from carrying around garbage cans filled with heavy weeds. On the other hand, I've had so many blood draws, CT-scans and infusions that I'm getting bored with them, and it will be interesting to undergo a new test administered by Nuclear Medicine (that's really the name of the department!). They inject you with something, I think radioactive waste from the Hanford Reservation, then you sit around for three hours to let it fully circulate (into your bones, I guess). After that they scan in some way. It will be interesting to see. Oh, I just got some new information: For the scan part you're supposed to drink lots of liquids and then lie flat on your back without moving for one to two hours. Yeah, right. I could also walk upside down on the ceiling while juggling seven hedgehogs and playing Rachmaninoff piano sonatas on the kazoo.

By the way, I was wrong about the first infusion being a half-dose. I was sure that's what they told me, but I was certainly pleased to learn that the second dose is the same as the first. Tom and Dana were there this time. Alway fun to see them.

Back to the fatigue: Sometimes I feel like I need to lie down every two hours. But I did the 9-mile hike, and of course remain true to my motto: If you don't feel like going out for a walk, you should immediately go out for a walk. Today for instance I did a double-hiller in the park. Although I felt fine during it, by the time I got back to the house I felt ready to collapse. I've discovered though, my motto notwithstanding, that it's best not to fight it too much. It seems ridiculous to lie down for a nap when I just had one two hours before, but it makes the fatigue manageable. Surprisingly, I'm even getting some good work done. Although I've been a total has-been in research the last few years, I'm actually writing a paper with my student (``The Duflot filtration in equivariant topology'', if you were dying to know). We'll probably submit it to a top journal such as Quilter's Corner or The Bass-Fishing Almanac. In any case, it's nice to feel I'm doing something again, modest though it may be.

The most exciting recent event was Mikayla Weissman's wedding. I could write a whole blog about that, but I'm running out of steam and will just say: Beautiful wedding. Beautiful bride. Amazing family. Amazing friends. Wonderful!

Pembro report: so far, so good!

My first pembro infusion was a non-event, as I more or less expected. I hope it continues to be uneventful!

Both of my previous Nurse Practicioners have moved on to other jobs, including alas Sarah the opera fan. The new one, Lisa, is not an opera fan (which surprised me because I thought this was a prerequisite for working in the urology clinic). Lisa has experience with pembro, although mostly with melanoma and lung cancer. She was very positive about pembro being a low-impact treatment. According to her, the most common side-effects in order of frequency are (1) fatigue, (2) dry, itchy skin, and (3) diarrhea. Many patients, she says, continue whatever they were doing before with no problems. Excellent! I can return to my plan of one-upping Alex Honnold, who's gotten a lot of press for his recent free-solo of the ``Freerider'' route on El Capitan. Oh come on, he rehearsed the route with a rope multiple times before going ropeless, and took four hours to do it. And it's only 5.12D, what's the big deal? My plan is to do it on-sight, at night, in under forty minutes.

The immunotherapy infusions are shorter and simpler than the chemo. First I go to the urology clinic where Deanna ``accesses'' my chestport and takes out a couple of gallons of blood for testing. Or maybe it was three teaspoons, something like that. At the first withdrawal she remarked ``oh, this is old blood''. Excuse me? Whose blood are you calling old! It's an hour 30 min. appointment, and although it doesn't take quite that long, it has to be done as a sterile procedure and that drags it out a bit.

Up in 8th floor southeast, I was disappointed not to see any of the old gang besides Rose. Tom, Dana, Glen, et. al. were all off travelling or otherwise enjoying themselves, the nerve! My infusion nurse was a new one (new to me, I mean) named Alyson. She's about my age, I think, and just got back from a bicycle vacation in Italy, in the region around Torino that we visited last September. She even speaks a little Italian, so that was fun. Like me, her first foreign language was French. After college she worked as a nanny in Paris for a while, and told me this story: In the US she often donated blood. Afterwards they give you a few crackers and a cup of orange juice. She thought ``why not donate blood in France as well''? So she did, and afterwards got a complete lunch with choice of red or white wine, followed by a sugar cube dipped in cognac.

The infusion part of the appointment was under two hours. They start you with a half-dose, then in three weeks decide if you can tolerate a full dose. So far, so good...

Had a great time at the Mariners' game last Sunday. Of course, it's always fun to be with the Brown family, but also we had great seats and it was a good game (2-run homer by Cruz, spectacular catch in left field by Powell...). It amazes me what a long attention span Kaia and Finley have for these games. For some time now they've both known how to read the scoreboard, and Finley keeps up a running commentary: ``It's looking good, guys! Runners on the corners, only one out, two balls and no strikes!''

In any case, there really isn't that much to report. No news is good news!

Follow-up to last post; decision made

There are several things I want to say in this follow-up to my previous post. First of all, I'm concerned I may have unduly upset some people with my funeral fantasy. That is the opposite of my intent. It's true that a big part of the purpose of this blog is purely selfish: It makes me feel much better to get these things out in the open. On the other hand, I really do believe that death after a full life is not some kind of tragedy. It is just a part of life and not to be feared. By making light of the situation, I am trying to convince family and friends to share this belief and not worry about me.

Second, the fatalistic tone of some of my blog posts should not be intrepreted as meaning that I'm giving up. Not at all. Indeed my problem is the opposite: Throughout the experience (chemo aside) I have consistently felt so good that without a dose of reality I could easily just ignore the diagnosis and proceed merrily along as though nothing was wrong. I need those dire statistics as a motivator to action. I publicize them in my blog because (a) as already mentioned, it is part of my way of dealing with it, and (b) it's important for other people to know. I don't want to write only a happy-go-lucky blog and then suddenly announce to my daughters ``oh, by the way, I have about three months to live''. I am doing my best to fight the cancer, but with a realistic attitude and without regarding death as some kind of injustice.

In fact another fantasy is that I am the first person to be totally cured by immunotherapy (see below for the decision). This would be very embarrassing, given all my dramatic posts about death. But I suppose I could live with the embarrassment.

Meanwhile, I'm happy, I'm enjoying life and just taking it day by day. You might be surprised to know what Wendy and I did on Wednesday evening, the day we got the scan report. We watched the last three episodes of season 13 of ER! Only two seasons to go...The next day I went to the Honors Luncheon, where a sophomore, junior, and senior from my differential geometry class were all getting awards as top students in their respective years. Another student from my mathematical reasoning class a year ago also got an award, so it was fun. A second top junior who I'd never met was sitting next to me. He's 17 and already taking graduate courses (I'm telling you, it's something in the air around here). Next year he'll be taking another grad course, called ``Manifolds'', which as it happens I will be teaching. At least a couple of these top undergrads will be in the course, which makes me all the more excited about teaching it. It's a year-long course, so obviously I must postpone croaking until at least next June.

After that I took my CRV to the dealer for new tires and a new battery. Hiking season is upon us, and it's no fun to be stuck at a trailhead with a dead battery (it's happened to me just once in my hiking life). However, I really am a total dork: for years I've just been hanging out at the nearby Starbucks doing math while they work on my car, although on sunny days I've wished there was a nice park nearby. Only now, and this is truly the epitome of dork-dom, did it occur to me to just look on my cell-phone map! There is a very nice little park just a block or two away. Never noticed it before. As any Seattle reader knows, Thursday was an absolutely beautiful day. After tiring of math, and with the caffeine wearing off, I just laid down on the grass looking up at the sky and the trees.

In spring quarter I restarted my Italian lessons with Elisabetta. As is our standard procedure now, I come in and tell her about and/or read aloud from my current novel (which Elisabetta recommended to me), ``The Charterhouse of Parma'' by Stendhal (pen-name of 19th century French author Marie-Henri Beyle). It's a good story and a lot of fun because it takes place in northern Italy with many familiar locations; of course for us it us ``La Certosa di Parma''. I use these lessons to deceive the cancer in the same way that the young woman of ``A thousand and one Arabian nights'' deceives the Sultan. After all, I can't stop before the end of the novel! I need to find another really long one, not War and Peace but maybe The Brothers Karamazov. Even the cancer will hold off to see how it ends.

Now, on to my third point: I've decided to go with the pembro. I do in fact have access to the New England Journal of Medicine (I knew this, but as I said, I'm a dork) and have now seen the entire article on the pembro study. Some readers have suggested that I've been overstating the probability of serious side-effects, and perhaps this is true. I do worry about it, but in the NEJM study the percentage of grade 3 or higher ``adverse events'' is 15 percent, which maybe is not so bad. The main reason for my decision, however, is simply that doing nothing does not seem like an acceptable option. I don't want to reach a point where it's too late to do anything---and this really could happen within a few months, conceivably---without having at least tried SOMETHING. The pembro appears to be the best available option. In the study it had about a 20 percent probability of ``objective response'', and in some cases the response lasts up to 12 months. Having liver metastases, however, lowers your odds (here's one of those grim statistics): according to the study, 145 out of 186 subjects with liver metastases are now dead. The bottom line is that to me, pembro is not the great advance that its proponents make it out to be (bear in mind the study is funded largely by the Merck corporation, which markets the drug). Nevertheless, it is recommended by my oncologist and really seems the only option. On the plus side, infusions are only once every three weeks.

Just making the decision is a big relief. Thanks for listening, and have a fabulous day!

Scan report: not good news...

I begin with my standard advisory: If you're squeamish about urinary symptoms, or about me talking about my own death, read no further.

It's been an interesting week. For the last five days I've had more or less continuous blood, and blood clots, coming out in the old urine. I assumed this meant the tumor was growing again in the bladder, but according to the onc, bleeding from a bladder tumor is ``like sunspots''; you can't really predict when it will happen and for how long. According to Monday's CT-scan, the tumor in the bladder has not really grown after all. In any case, there is no pain from it and indeed it doesn't affect me at all, other than being rather gross---for that last reason I thought I'd share it with y'all. Some of those clots, man, how did they make it through?

That's the good news. The bad news is that the cancer in the liver has increased significantly. The biggest lesion has gone from 4.2 by 3.7 cm to 6.6 by 6.2, and the other big one from 1.6 by 1.1 to 2.4 by 2.2. There are also ``multiple new satellite nodes'' surrounding the big lesion. For those who are rusty on the metric system, 6.6cm is on the order of two and a half inches. I saw the actual pictures too; relative to the size of the liver, it can no longer be called a small lesion. In addition, for the first time my blood analysis is showing some effects of the cancer on liver function. I still don't feel anything though; in fact if anything I've felt exceptionally good lately.

So I am at a critical point. If it keeps growing at that rate, the end could be much closer than I would like to believe. Certainly the oncologist's body language gave me a very negative impression. This brings me back to the immunotherapy decision. I suspect (and in at least one case know) that to many of my dear readers it probably seems an easy decision, under the circumstances. Wouldn't I immediately start the immunotherapy, as the best and possibly last hope?

But it's not that easy for me; far from it. In fact I fear, dread, and loathe the prospect of immunotherapy, for reasons I've discussed before. If the side-effects were temporary, I would have no hesitation in giving it a try. It's the thought of permanent side-effects, some of which really can be awful, that gives me pause. Needless to say, in this context ``permanent'' means up until the point the cancer gets me, an outcome which appears increasingly likely. That's just the point: as I see it, the choice is between (a) dying sooner but enjoying the time that remains more, and (b) living longer but with diarrhea, nausea, headaches, shortness of breath, skin rash, and in the end, in the worst case, dying from the treatment itself. There is always, of course, the third possibility of a miraculous cure, but absolutely no scientific reason to believe in it.

Today's discussion with the onc did nothing to alleviate these fears. On the contrary, he had some disconcerting news: A recent, randomized study of atezo showed that, statistically, it had no benefits at all! Great. Now he thinks I should try pembrolizumab, another checkpoint inhibitor that supposedly fared better in a recent trial. But what's to say that pembro won't go the same way as the atezo? And it has the same suite of gruesome side-effects, as far as I can tell. I've been looking around online, and haven't yet been able to access the actual article in the New England Journal of Medicine (maybe my wonderful sister Victoria can get it). But I've read the abstracts and various other blurbs. One proponent waxes enthusiastic about pembro because (in the study) patients getting pembro lived on average three months longer than patients getting second-line chemo. Well, excuse me if I don't get too excited about that. First of all the relevant statistic would be average survival time for pembro versus no therapy at all, and in any case three months is not a figure I'm going to jump up and down about---assuming I'm even able to do so with pembro attacking my lungs.

By the way, the trade name of pembro is ``Keytruda'', manufactured by the Merck corporation. Even on the Merck site, the list of possible side-effects is discouraging to say the least. It's true that some of them are rare. Others are common. And all this for only a twenty percent chance (according to the study) of getting even a temporary benefit. I honestly don't know what I'm going to do.

There is a daydream I have about my own death. It may seem silly, or pretentious, or both, but at this point I don't really care. It's a comforting daydream for me, oddly enough. It has elements of Lou Gehrig's famous speech, of the scene in ``Tom Sawyer'' where Tom and Huck attend their own funeral, and of a low-budget off-Broadway version of the Last Supper.

It's a large dinner gathering. Friends and family are there. The occasion for the dinner is unclear, but it falls on me to make a speech:

``I want to take this opportunity to invite you all to my upcoming funeral, date TBA. I won't be there, of course, but there are a few things I'd really like you to do: Wear bright, colorful clothes. Play upbeat, happy music. Laugh, a lot. Have an Immortal IPA, in remembrance of me.

``You see, my death is not an occasion to mourn. I've been incredibly lucky in life from day one, from the family I was born into, to my wonderful wife and children and grandchildren, to my friends, my work, my health. Yes, even my health. Think about it: I've never so much as sprained an ankle, let alone broken a bone. I fell 150 feet in Yosemite, and came out of it with just a concussion and a broken nose. I had a mild form of epilepsy as a child, but even that went away; for 65 years I've never had a serious illness. Even with cancer I'm lucky: a world-class medical center is just a short, beautiful walk from my office.

``Hell, during the Vietnam war, my draft lottery number was something like 343, meaning there was virtually zero chance I would be drafted. I've led a charmed life really. If I believed in God, and had a chance to chat with him/her/it, I think I'd start by saying, ``Dude, thanks so much for a great life! It's been a wonderful run.'' After that I might get into the question of why I should be so lucky and others not. Things could go downhill and I could end up in the Bad Place. But I don't believe in God, so I won't worry about that.

``By the way, with regard to my ashes: please dispose of them in an environmentally responsible manner. I would be honored if you went to visit one of my favorite mountain haunts, but I sure as heck don't want you carting a box of ashes around and freaking out the marmots. Just take your thoughts, and mine, with you. And be happy.

``So good night, I love you all, and remember this: If I catch anyone at my funeral wearing somber clothes or playing gloomy music, I'm going to be really pissed off.''

Back to reality: The sun is back, at last, in Seattle. Kaia's butterflies have emerged from their cocoons, and have been set free. It's a beautiful world.

Indecision point

The latest suggested immunotherapy is called ``nivolumab'', or ``nivo'' for short. Both nivo and atezo are known as ``immune checkpoint inhibitors'', the difference being that nivo tries to block PD-1 (``death cells'') whereas atezo tries to block PDL-1 (``death cell ligands''). I originally thought the PD-1's were the good guys and the PDL-1's the bad guys, but apparently the game is just to prevent by whatever means necessary the linking of the PDL-1's (which are on the cancer cells) to the PD-1's (which are on the good cells). This frees the cavalry to charge out to the rescue and attack the cancer cells. Well, obviously I don't yet understand the biology here, but in any case such understanding only serves to satisfy intellectual curiosity---it doesn't help make the decision.

The one major study of nivo involved 275 patients. It had a somewhat higher ``objective response rate'' than the atezo study, although with such small sample sizes I doubt this is statistically significant. The side-effects are the same, with fatigue and colitis (diarrhea) being the most common. The colitis sounds like it can be bad enough to prevent you from doing much of anything. Supposedly it can be treated with steroids, which of course have their own nasty side-effects. Moreover the colitis doesn't necessarily go away when the treatment is stopped. Without meaning to be overly cynical, I will also mention that the nivo study was funded by Bristol-Squibb, the company that makes and sells the drug. All things considered, then, I am much less enthusiastic than the authors of the study about the prospects of nivo (or atezo).

I wish it were possible to get case studies. Was the typical patient a 98-year old chain-smoking alchoholic with a bad heart and a wooden leg? Or was it a robust young man in the prime of health like myself? I wish I could obtain individual reports or accounts written by the patients themselves. It's very hard to know what to make of the statistics, since the definitions of partial response, complete response and so on are so vague.

The oncologist favors atezo over nivo, because (a) the infusions are once every three weeks for the former and every two weeks for the latter, and (b) atezo is cheaper and therefore a better choice for the common good. Well, I certainly want to do my part for the common good, although I confess item (a) would be the deciding factor for me---assuming I go this route at all. Once again I asked him what he thought would be the likely outcome if I choose no therapy at all. After stressing that there is no such thing as a ``median patient'', he said the median survival would be six months. I knew this from the literature already, but wanted to hear it from him. Of course, as I've said before, I would be mortified to only reach the median; the sheer embarassment of croaking that quickly would motivate me to beat the odds.

The oncologist seemed okay with the idea that I wait for the next scan before deciding, although I think this is because he's given up on convincing me to play a conservative game. The fact is that I still don't know what I will do. No one can help me with this decision (and I must say I'm very grateful that no one---doctors, family, friends---has pressured me to do anything). It's all on me, as it should be. Despite that dire ``six months'' figure, one side of me wants to say screw it, I'm going to put off therapy indefinitely and keep focusing on enjoying life now. The colitis (says the doc) can mean ten or more diarrhea attacks a day, which would put a bit of a damper on enjoyment, or even functioning. I wouldn't mind risking this if I knew it could be stopped by stopping the therapy, but the thought of a permanent such condition is pretty repulsive. And how bad is the fatigue? This is the kind of information that's impossible to get. There are other side-effects too.

I take much inspiration from Tiziano Terzani. He eventually reached a point where he said enough is enough; I'm done with treatments, I'll enjoy life now and accept death when it comes. Now admittedly, Terzani pursued treatment options much more extensively than I have. He spent a lot of time at Sloan-Kettering in New York undergoing chemo and radio (ironically, our cab from JFK went right past Sloan-Kettering on the way to meet Abby), and then travelled the world experimenting with various ``Eastern'' and even New Age-y approaches. He didn't really believe in most of these; the trip was motivated also by journalistic curiosity and led to his book ``Another spin on the merry-go-round''. Terzani also had a much more highly developed personal philosophy than I do, based in part on his extensive studies of Hindu and Buddhist ideas. Nevertheless, in my own way, I feel a strong connection to his point of view.

Would I have been better off not interrupting my chemo to go to Italy? From the conservative point of view, i.e. of maximizing life-span at all costs, maybe yes. But I'm not going to do that. Would I have been better off starting immunotherapy last month, even if it rendered our New York trip impossible? Conservatively, maybe yes. But I am very, very glad that I didn't jeopardize the trip. We had a fantastic time visiting Abby and Oliver. I'm not going to forego living for the sake of living longer.

Maybe I should decide just how long I'm going to procrastinate. But not today. The sun is out, and life is wonderful!

Of bladders and bobcats

The purpose of this follow-up post is to report on the actual scan results, which I've just received. However, I have to also report an unusual wildlife sighting on the Pipeline Trail (which goes up from the Sammamish river valley along the Pipeline right-of-way): a very large bobcat. By "large" I mean that when you first spot it out of the corner of your eye, you think it's a dog on the order of a German shepherd. It is then a bit disconcerting to realize that it is clearly a member of the cat family. A mountain lion? But the coloring is all wrong, with the spotted fur pattern. As soon as it saw me it lay down in the low bushes, so I couldn't see if it had a tail; indeed it was so well camouflaged that I hadn't already known it was there, I wouldn't have noticed it at all. Finally I decided to lob a couple of small rocks its way, just to be absolutely sure it wasn't a mountain lion (in which case a 911 call would be in order, with all the houses around). It jumped up and ran off, clearly a bobcat. But a HUGE one. I had no idea they got that big (up to 65 pounds or so, as I later checked).

Now, as to the scan. This one illustrates why I want to see it myself, as what the oncologist tells me over the phone is not necessarily the complete story. If you're interested in such things, here are some actual excerpts:


Liver: Significant interval increase in size of segment 7 hepatic metastatic
lesion (3/120), measuring 4.4 x 4.0 cm, previously 2.7 x 2.0 cm. Previously
noted small left satellite nodules is no longer identifiable on today's CT.
There is a new 1.6 x 1.1 cm lesion in the segment 6 (3/154).

An then in the summary:

1. Significant interval worsening of hepatic metastatic disease with new
lesion in the segment 6 and significantly enlarging known segment 7 lesion.
2. Unchanged thickening of the inferior urinary bladder walls, consistent with
primary bladder cancer.
3. Unchanged retroperitoneal and pelvic lymph nodes.
4. No evidence of new disease.

The doc didn't mention the "new lesion", but maybe it's another mirage. In any case, as I already knew, it's not exactly good news. But hardly surprising. Also, I think he's stretching it a bit to say that my bladder is "pristine". I can see the ad now at Al's Used Bladder Emporium: "Almost like new! Top quality bladder in pristine condition, used only on Sundays by a little old mathematician!"

The radiologist looks at everything in the abdomen/pelvic area, and had this to say about my hip replacement: "No evidence of hardware failure." Well, that's good to know!

Another scan, and a very happy Wendy birthday

Last Monday's scan showed that the original lesion in my liver has again increased in size, but ``not dramatically'', to quote the oncologist. On the other hand, the second apparent lesion now appears to have been a mirage. So that's good news, although I myself have not yet seen the radiologist's report. It really irks me that they're so slow to forward it to me. The doc also said that my bladder looked ``pristine''. It's not often you hear those two words used in the same sentence.

He also told me about a new treatment as a possible alternative to atezo. I'll report on that later, when I've had a chance to investigate. For now I'm just looking forward to our New York City trip, coming up on Wednesday! We're going to see Abby in the chorus of Fidelio at the Met, and we're all going to see Aida as well. It will be great to see Abby and Oliver in their native habitat.

Not to mention I'll finally meet the legendary Earl Grey (the cat).

Meanwhile, we had a wonderful celebration of Wendy's xx-th birthday, where the number has been censored because I can't believe a young man like myself is married to a woman that old. On the Saturday we went out for dinner and then saw the movie ``A United Kingdom'', which is fabulous. Very highly recommended. On Sunday, her actual birthday, we had birthday dinner at the Brown's house. Now, it is well-known that Kaia and Finley are the cutest grandkids on the planet, as has been verified by an independent research firm. But they really outdid themselves this time:

They met Wendy at the door and sang Happy Birthday to her. Kaia made a colorful Happy Birthday poster. They each made a present for her out of cardboard etc.: Kaia made a Boeing airplane, and Finley made a doll house (``Be careful! It's fragile!'' he warned). Kaia helped her mother make a strawberry birthday cake, in the shape of a strawberry (according to Kaia, ``I told mommy how to make it''). My favorite image of the evening, which makes me smile just to think about it, is Kaia serving cake and icecream while wearing a cute little apron and a white chef's hat. Would you like one strawberry or two? she asked each of us. Later she announced that she was going to go around the table and give each of us a hug, which she did. Finley decided to make a present for his daddy. ``Don't look over here!'' he exclaimed about once a minute. ``Guys, don't look at the art table!'' It turned out to be a Star Wars vehicle---the name of which I forget, not being a connoisseur of the form as Finley is. Meanwhile, Kaia was whispering to me about her plans for Daddy's birthday cake (his being the next family birthday coming up).

It doesn't get any cuter than that! Life is beautiful, indeed.