Wilfred Convers Peacock-Gentry and his grandfather
(With apologies to Reader’s Digest for stealing their line…)
This is a happy, pretty uneventful update. For those who haven’t been introduced on Facebook, this is my grandson, Wil, making his grandfather’s day. What an amazing experience to share these early weeks of his life with his parents and him. He was just about 6 weeks old when the photo was taken. Some observant gazers can see that I’m trying to race Wil in terms of growing hair, and I believe I’ll win. I even had to start shaving a couple of weeks ago, which is a morning chore I did not miss during the four months of chemo.
If you have followed our earlier updates, the main goal for the summer was to finish the regular treatment round of chemo (sometimes called AIM – for Adriamycin – Ifosfamide – Mesna), and then get ourselves to Betsy’s family’s place in the Adirondack Mountains. Once there, the prescription was getting to know our grandson, welcoming my family for a reunion, and enjoying the extended family, other relatives, and extraordinary surroundings here in the Adirondacks.
I’m feeling as good as I’ve ever felt this year, with the exception of the still diminished stamina. Shorter walks instead of real hikes and no mountain climbing, and at least one nap, and early bedtimes have been the pattern. I’m more than a month past the last chemo treatment, and there really is no residual effect from that. Betsy and I lined up relationships with a local family practitioner, and then our oncologist in Medford got in touch with the local oncologist here (who commutes here two days a week from the University of Vermont in Burlington). We’ve had appointments with everyone and hope/expect we won’t need much else for awhile. The local oncology clinic can flush my IV port once a month and monitor lab tests, but we are not planning any active treatment or intervention while here.
I keep looking for simple ways to describe the next stage of the journey. The unknown is how quickly and aggressively the tumors will grow and multiply. We know that they will. It could be a long, gradual process which would give us a nice period of quality time, or we’re told that sometimes they will be very aggressive once chemo is over. So my current “mental model” is the glide path of a plane. We may glide on currents for a longer time, or lose that lift sooner than we would like.
Meanwhile, what patient would not benefit from that little boy’s smile?
We just had our last medical appointment before our trip east. It included a chest CT scan in the morning, so that the results would be available for our meeting later in the day. The bottom line is that the 3 rounds of ifosfamide did a good job of shrinking many of the tumors – better than the course of treatment that included the doxorubicin. I had hit my lifetime maximum dosage for doxorubicin (which is potentially harmful to the heart) and my oncologist felt we had hit a point of diminishing returns with it in any case. So the last round of inpatient chemo just included the ifosfamide.
The larger tumors showed the most reduction in size. A good example is one in the pleural space just outside the lung, which went from 3.3 x 2.6 cm down to 1.8 x 1.2 cm. Some of the very small lesions were unchanged.
Classic glass half-full vs. half-empty scenario. The ifosfamide did a nice job of holding back the growth of the tumors and shrinking the larger ones. Nothing but happy news there. But nothing has vanished. No miracle disappearance. We don’t know how quickly they will grow back or others appear.
I’m feeling pretty good. No need for a transfusion, post-chemo, this time. My red blood cells rebounded from the treatment nicely. No neutropenia, which is the side effect of losing a bunch of white blood cells and infection-fighting capability. The nicest thing about the red blood cells rebounding is having a higher level of energy, relatively speaking. And without the doxorubicin this time around I haven’t been bothered by mouth sores. This bodes well for the next number of weeks. I’m expecting to feel better the further away I am from the chemo.
So, we’re off on our eastern adventure. Betsy and I fly to the Adirondacks on Tuesday the 25th. We’ll husband my energy a bit and spend Tuesday night in Albany and then do the three hour drive to the lake Wednesday morning. Meanwhile, a friend through Rotary is driving our dog, Casey, and our car across the country. He just called in from central Nebraska, and will probably beat us to our destination by 18 hours or so. Our daughter, Katy, will arrive in time in play host to our friend. He’ll have a day or so to relax and see the place and then we’ve arranged plane tickets for him to fly home. What an amazing offer and help to us.
Just days later our son, daughter-in-law, and brand new grandson will arrive and spend much of July with us. Plenty of quality grandparenting time ahead of us. And my Dad, siblings, and their spouses will join us mid-month for a reunion postponed from last summer. And good friends arrive earlier in the month. A busy, wonderful time.
No more chemo or treatment plans for the summer, though we have hooked up with an oncologist who comes down two days a week from the University of Vermont to see patients at our local hospital, and we’ve also made arrangements to see a family practitioner in the area, just in case some symptoms need tending.
Our plans are pretty vague beyond that. If my health holds up we hope to stay at the lake into September, then return to Ashland. If my health changes quickly we’ll re-evaluate.
Two recommendations for blog posts for you all. First, for those who didn’t see my link on Facebook, here’s a lovely, heartfelt, and a sad/happy reflection our son Philip did just after Father’s Day. He’s a father now, and it prompted him to write: http://blog.pmgentry.net
And then I came across the blog from another cancer traveler. This particular post felt about right to me, though I’m a bit impatient with some of his others. http://theoneeyeddog.tumblr.com/post/53358703876/i-have-cancer-but-dont-call-me-brave
Straightening out my office I’ve had a chance to look through the piles and piles of notes and get well cards that have come over the past year. What a reservoir of love and support.
I’m in the hospital with my second round of inpatient infusions. Pretty uneventful. I’ve got the routine down, and the schedule is similar to last time. That means that the process starts around noon, and continues until about 3 in the morning. Early drugs, pre-hydration, the actual chemo agents, more other drugs and more hydration. Lots of trips to the bathroom to make sure I’m flushing the bad stuff out quickly.
The only different side effect this time is a flush/rash on my face. The doctor thinks it is a reaction to the steroids, which are part of the “other drugs” I get. We’ll watch it, but otherwise nothing serious.
I guess coincidentally, but perhaps because I have the time and my mind is on cancer, I came across this story of a 17 year old boy who was diagnosed with osteosarcoma – the bone cancer version of my sarcoma. He went through some surgeries and chemotherapy, but then last year, had a routine CT scan and discovered metastases in his pelvis and lungs. That last part is very much like me. He was told he had 6-12 months to live and that his treatment options were pretty much exhausted. So the story and the song, Clouds, are focused on his remaining life.
He’s a neat kid and I encourage you to watch the mini-documentary that I’ll link to down below. He may focus too much on cars and talk about marriage to his high school girl friend, but I admire his 17 year old spirit. And I watch his family and friends both embrace that spirit and dread the day it is gone. I think it is his sister who talks about the moment she fears is walking out of the hospital once he has died and knowing she’ll never see him again. That hit me hard. Zach died yesterday – May 20, 2013.
I’m not good at figuring out or paying attention to song lyrics, but I like his song, Clouds. I’m going to link to the version of the song where his family and friends are lip synching. It’s more touching. I’ve downloaded it to iTunes so I can listen offline.
We’re aways away from the heavy talk and thinking times. We have the excitement about the pending arrival of our first grandchild, and making plans to get back to the lake in late June, and the fun family gatherings that ensue. Every now and then something comes up at dinner conversation that makes Betsy and me pause or sniff, and of course sitting here in a hospital brings more out. Betsy and I agree that looking ahead a year from now seems as distant as the moon. A lot depends on whether this treatment slows the growth of the tumors, and if it does, how quickly they will rebound after treatment ends.
So, with the exception of spirit/strength lessons from some 17 year old kid on YouTube, all the logistics and excitement about summer plans keep my spirits up these days.
Here is the mini-documentary about Zach. I’m just going to include the link. I have trouble embedding YT videos in my blog.
Here is a link to Clouds:
Packed red blood cells
Blood doped…boosted…performance enhancing… That’s me today. I spent the day, as an outpatient, at RRMC up in Medford, being everything but an inpatient. I received two units of packed red blood cells, to boost my own supply of them which is shrinking. My hemoglobin and related counts weren’t dangerous, and we expect them to dip for awhile after chemotherapy, but my oncologist wanted to stop a trend that wasn’t correcting itself. To my friends Melanie and Ben – don’t tell Mac that I’m engaging in what I think is the actual doping activity that snagged Lance Armstrong. I want to be able to look him in the eye next time we meet.
We figured it would be a number of hours, but not 8 hours which was the clock in to clock out duration. I was there long enough to order a hospital lunch, have a one-pump buddy, and some of the nurses I had met during my longer stay came by to say, “Hi.” I’m supposed to have more energy, and maybe less shortness of breath. I think that’s already the case, but we’ll see tomorrow for sure.
This past week has been spent mostly dealing with the sometime minor side-effects: dry mouth and sores in the mouth, and a runny nose.
The cells lining the mouth are part of the fast growing variety which chemo agents attack. I’ve been pretty good about keep my mouth hydrated and they recommend a daily, non-alcohol based mouthwash, but those precautions didn’t work this week. My mouth has been pretty sore, and I’ve sprouted some thrush which is a fungal infection that Betsy remembers either giving to or getting it from Philip while she was nursing. The first level treatment is this prescription generically called Miracle Mouthwash. Depending on the doctor and the patient’s condition it will have some lidocaine, some Maalox or similar to coat the mouth, some nystatin to fight the thrush, and somtimes benadryl. We’ll hope it all clears reasonably soon. Meanwhile my food portions are soft and small. Ice cream that has started to melt fits the bill admirably.
And then the runny nose. They never told us about this in all the literature. So, a little review… we all have little hairs in our nose that trap floating particles in the air as we inhale. And I guess there is a small but steady flow of nasal/sinous fluid that mixes with the hair and the particles and makes, well, snot. Only I don’t have any nose hairs at the moment. (This could be calamitous but I can’t imagine why, except for Richard Thalheimer who always sold those stainless steel nose hair trimmers. Maybe an increase in adult cancer was one of the causes of the business failure of The Sharper Image.) So, back to me… with no hairs, the particles go in my lungs I guess or maybe land on the lining. And the fluid is still flowing. So the consequence is that I’m going through more handkerchiefs, and don’t look too closely at my sleeves.
See all the interesting things you learn in this blog?
Next step on the journey is returning to the hospital on Monday, May 20 for another round of the two-headed agents.
On Facebook the other day I introduced my “three pump buddy.” It’s central to my 4 day hospital stay here at Rogue Regional Medical Center.
My chemotherapy regimen includes a drug that has some potentially nasty side effects, including on the bladder, and the doctors prefer giving the drug in the hospital where I can have lots of fluid pumped through that bladder and I can be monitored closely.
From my Facebook post:
Meet my triple pump buddy. We’re inseparable from mid-afternoon, through the night, then get a break from each other in the morning. She has a battery so I can wander or find the bathroom with her. Biggest problem…she snores.
More specifically I get hooked up to my buddy in the middle of the afternoon. I have an IV port implanted just under my right collar bone, and all this week a port connection is dangling from it, and it is a relative snap for the nurse to attach the machine to the port. No needles in the arm or back of the hand as is more likely on a hospital visit. They can also do blood draws from it, avoiding the need to find a vein in my arm.
But once hooked up – I stay that way for 12-15 hours, through the administration of the extra hydration, the anti-nausea, anti-bladder infection drugs, the chemo agents, and more hydration. Every trip to the bathroom, or journey down the hall, or walking over to pickup the iPad, or order dinner on the room phone, or move from bed to chair, requires me to bring her along. She’s on nice, broad rolling wheels, and though she is usually plugged in, she can be unplugged and work off batteries for an hour or so. When I get up in the middle of the night (many times, thanks to the hydration) I have to unplug her, wheel her in front of me into the bathroom, set her aside but within catheter reach, etc. And she does snore – there’s a fairly loud pumping sound, different for each drug and its infusion rate, etc. I’m lucky to be able to sleep through that – it becomes white noise.
None of this “leashed” experience is horrible, just something annoying added to the mix. And I’ve had an interesting set of similar partners along the way. In the hospital for the first surgeries last year, I had the obligatory IV placed in the back of my hand. The catheter gets taped securely, so there’s no chance of pulling it out or dislodging it. And as with my triple pump buddy the IV was on a rolling stand so I wasn’t stuck lying in bed. But it was constraining, even to the point of scratching my nose or pulling up the bedsheets.
Then, off and on for almost three months I had this little guy as a constant companion. The Wound Vac had an airtight dressing over the wound on my back where the original tumor was removed. The wound was slow to heal and the negative pressure helped draw healing tissue to the site and also helped adhere the skin and muscles layers that had gotten separated. I had a little satchel with the Vac to sling over my shoulder, with a tube running to the wound site. The battery lasted 12-15 hours and then needed an overnight charge. So at night, I plugged the satchel into an outlet near my bed, and would have to unplug it and carry everything into the bathroom. Even into the shower – hanging the satchel outside the shower door, draping the tubing over the door while I stood in the shower. That connection was 24×7, and there were plenty of times when it felt like a ball and chain – particularly connected to a dressing which couldn’t be compromised.
So, a summary… it’s no fun being hooked up to a machine, though it’s certainly better to have the machine be portable. Each time I resolve to be as independent as possible with the machine constraints, but it is also a noticeable relief when I am disconnected. I don’t want to think about a future with an oxygen tank, though my oncologist says that the lung lesions aren’t likely to have that kind of impact.
Oh, and the update… I’m actually feeling pretty well here during this hospital stay. As with the outpatient chemo infusions, they gave me several hits of anti-nausea drugs and some steroids – which help hold off symptoms for about 3 days. So I’m still under their umbrella, but still relieved that the additional drug hasn’t done spectacularly bad things. With all the infusing during the night I’m not getting solid sleep, so naps are even nicer. All in all, this new journey has been more than OK.
Meet my triple pump buddy. We’re inseparable from mid-afternoon, through the night, then get a break from each other in the morning. She has a battery so I can wander or find the bathroom with her. Biggest problem…she snores.
Photo thanks to Iwan Gabovitch on Flickr
I promised more of an update once we had a chance to meet with the sarcoma specialist up at OHSU in Portland, and our local oncologist in Medford. Both appointments were good. Good discussion of options, making some more plans, and trying to make sense out of the various chest CT scans I’ve had over the last several months.
The CT scans show perhaps modest success with the lesions in my lungs. Maybe some are smaller; maybe some are about the same size; and no new guests. One larger growth, just outside my lower right lung, continues to grow, and on the same side, but near the top of the lung – perhaps just outside in the plura – has grown quite a bit. We’re basically measuring from a baseline scan done near the end of February, just before the start of chemotherapy, and then another done last week. There was an extra scan thrown in, in late March, and sometimes the radiologists and the oncologists got a bit confused when making before and after comparisons with that extra report thrown in.
So, Dr. Ryan at OHSU recommends we return to the first plan, which is chemotherapy with two agents – the doxorubicin that I’ve been receiving and ifosfamide (i – FOS – fa – mide). Dr. Ryan had found the European study that showed pretty conclusively that using both agents did not extend life expectancy more than just using doxorubicin alone. So I asked him what had changed in his thinking. He explained that my modest success with doxorubicin, coupled with my generally good tolerance of the treatment meant I was figuratively in a sub-segment of the target population, and perhaps it was worth trying both now. But as before he had to admit that there isn’t solid research ground to stand on here. Just his judgement and our wishes.
Our discussion with Dr. Dibb today in Medford ran roughly the same course. He had spoken with Dr. Ryan and compared notes, and he saw some value in trying the additional drug, if we were willing. There was some question of whether we might use radiation to attack the two most active tumors, but that means stopping any chemo, and his preference is not to let up on the systemic treatment now. We shared with him our desire to get to a pause in terms of treatments by late June, so that we could go to the Adirondacks and spend up to 3 months there. He and Dr. Ryan support that kind of plan. They’re good, compassionate doctors.
So, we’re throwing some more chips in the pot. The two agent treatment needs to be done on an inpatient basis. This Monday morning I’ll check myself into Rogue Regional Medical Center, the largest of the two hospitals up the road in Medford. The ifosfamide in particular gets metered into me in doses over some time, and it has side effects that need to be monitored throughout the day – hence the hospital location. I stay about 4 days, depending on the various lab tests and my condition.
So, it’s a bit of a gamble – risk of more/different side effects and the time in the hospital against the possibility of stronger impact on the lesions, which in turn might extend life expectancy. When I mentioned to our University Seminar office coordinator that one of the unlikely but possible side effects is hallucinations, she said she’d be on the lookout for an email from me, warning about the attack of the snakes or some such. I appreciate her vigilance.
The silver lining was that the infusion I was to get today is now put off until the hospital visit. So, both Betsy and I have a relatively unencumbered long weekend – though she has two Siskiyou Singers concerts to which she can devote her full energies now.
I’ll probably report at some point from the hospital or if I’m seeing snakes, Betsy may do the reporting.
Have a Nice Day
A friend wrote me a quick note the other day, saying she was thinking of me and hoping I wasn’t having too difficult a time with all of this. I thought about her kind concern and my almost knee jerk reaction, that, “Thanks, I’m doing fine.”
So, what are days as a cancer patient like? Well, clearly that answer depends a lot on the individual. I have read and seen and known enough examples of people for whom the journey is painful, frustrating, depressing, and just plain shitty. I am incredibly lucky to be able to say that those adjectives rarely apply to me, and never all at once.
So, my answer is a little more vague, and I’m going to use this post to try and sort through how I feel. Thank you for helping me with this. When I have more than a greeting-on-the-walkway conversation with someone who asks, I’ll tell them that I has this kind of low grade “ugh”, sort of like the feeling you get when a cold is coming on. That’s probably the lower energy levels caused by a low red blood cell count. And, of course, I’m hairless, though that is mostly a conversation piece and nothing that affects how I feel. I’ve been lucky to have avoided the common problems of nausea (no excuse to get an Oregon Medical Marijuana card) and my appetite is pretty good, though a bit smaller around the edges.
On one plane of consciousness (don’t worry – I won’t get all Zen or Buddhist on you) my days are pretty normal. I enjoy being with Betsy and hanging out at home and being part of the University community, and Rotary, and Ashland generally. We celebrate sunny days and hunker down on rainy ones. I see plenty of friends and colleagues at school, and have regular interactions, and need to solve problems, and I grade assignments in my online class and all the rest. I can generally save up energy so we can go see a play or a concert. Some days the schedule gets overly full, and my energy wanes and I either bail out or become something of a zombie. But wait – isn’t that pretty much like any of our days? That’s right. It’s pretty normal (except for the daily naps or bailing out part.) I interact with a wide group of people and that often is fun and fulfilling. This is particularly true of students I see on campus. I run into some I know and their excitement (or worry or whatever) is pretty rooted in the here and now. My conversation with them is not affected by my health status. And that is as it should be.
So, one answer to my friend who worries about me, “It’s not a big deal. Life goes on and is still full of interesting twists and turns and daily curlicues.”
But, of course there is that other plane of consciousness. Or to pick another metaphor, a parallel track – dealing with cancer. Mostly it is filled with logistics stuff. Pick up the CT scan report at the hospital. Make sure OHSU has all the records in preparation for our visit next week. Clear the calendar for the next infusion day and after. Try to figure out what will happen after this chemotherapy regime is finished in early June. Sometimes reality sets in, and I have to remind someone I’m probably not going to be on campus in the fall, and so can’t join a committee, or commit to a new initiative. I bought a new watch and briefly asked myself, “why?” but then, “why not?” So, this other plane or track is much more complicated, and it’s there some of the time. It’s too soon to be deeply philosophical about facing death, but to my friends I just need to say that “I’m fine – just at 3/4 speed and sometimes with a little shadow or cloud.”
Sugary Drink - photo by http://www.flickr.com/photos/bike/
For my Spring Term Microeconomics students – this topic comes up in our course in early May when we learn about market failures.
A former student, Tyler Voorhies, wrote on my Facebook timeline, talking about New York’s Mayor Bloomberg seeking to ban the sale of large size, sugar-containing sodas at restaurants in the City. Tyler wrote,
I’m a fan of it, obesity is one of the many issues plaguing the healthcare market and soda contributes directly to it. It’s the Pigovian tax on negative externalities, in a sense – which I think fits very well here. Most people seem to have a negative knee-jerk reaction to this idea, but i think their are some strong economic arguments to be made in support of this.
Here’s the economic argument in favor of some kind of ban. Tyler mentions negative externalities. In a regular, competitive market the consumer weighs the cost of a purchase, like a super-size soda, against his personal benefits. The seller of the soda does the same – comparing the cost of production against the price. The market price is at equilibrium and there is an efficient quantity demanded which equals the quantity sold. However, sometimes there are costs incurred by people other than the consumer and the seller. In the case of high calorie drinks, public health experts assert (and can demonstrate with reputable studies) that consumption of these drinks is linked to increases in obesity in the population and that increasing obesity leads to increasing healthcare costs. In numerous ways the costs of obesity are paid by society, through higher health insurance premiums, increasing uncompensated ER visits for diabetic emergencies and more. So our innocent market for soda understates the social costs. The equilibrium price and quantity are no longer efficient since they do not recognize these external costs. Those are negative externalities. This is a market failure and a possible rationale for government intervention.
Now, what to do about it. Tyler noted that a New York court struck down the proposed ban on the sale of super-sized sodas. Maybe a Pigovian tax would work. Yes – in theory, that would be an even better approach. Readers – see the Pigovian Tax category in the list of categories on the left for more information. How might it work here? There could be a tax on sugar or calories in drinks or food served in eateries. This tax brings the external cost of unhealthy eating into the purchase decision. Consumers pay a bit more and in theory reduce their consumption to some extent. And government collects tax revenue that could be used to offset the social costs of obesity (or could be used in public education campaigns similar to no smoking efforts.) Pigovian taxes are designed to provide incentives and change behavior, but they preserve the public’s right to make their own consumption decisions. Even right of center economists, like Harvard’s N. Gregory Mankiw, favor Pigovian taxes as an alternative to direct government regulation like Bloomberg’s proposed ban.
So, hat tip to Tyler for remembering his old Econ teacher and for giving me the opportunity to bring a current event into this blog.
“Your appetite seems pretty good,” Betsy said. “Yes, it is,” I replied. Only Betsy wasn’t talking to me; she was talking to our dog. Moral of the story – it’s not always about me.
This little episode added to some reflection I have been doing lately. Of necessity I have to be pretty self-aware – keeping track of symptoms or changes in normal “systems.” It’s almost a form of narcissism. The oncology folks have a laundry list of things to be on the lookout for. Top of that list is anything suggesting an infection or leading up to one. The chemotherapy lowers my white blood cell count and lowers my resistance, so if some bug does invade, the response is often hospitalization and IV antibiotics. And there is a cycle with each chemo treatment. The first three days are schizophrenic – overall the body is tired from the recent assault, but the infusion includes a bunch of bracers, including steroids, and they add some zip to the tired body. Then that concentrated dose wears off and we go through the first week of feeling more tired, wondering if the nausea will appear, and just getting through the day. Then there is the social quarantine period (10-14 days after the infusion), where I’m supposed to be extra careful about contacts with others. And finally a week where the world looks a bit brighter, though hair may be falling out. These are all things that I notice about myself and need to keep track of.
All this self-awareness, while necessary I guess, isn’t good for the soul. Or at least it doesn’t feel so good to me. Friends call and ask how I’m doing and I can give them a litany, and usually I think they genuinely want to know. But there’s an odd cadence to those conversations, and I’d be happier knowing how things are with them. I’m more glued to Facebook these days (I know – a bad sign probably) but I love seeing the little stories and photos and experiences my friends are going through. There are young, school age kids in our neighborhood who are waking up with spring, and riding their bikes, building forts, and modifying their swing. Those are pretty therapeutic events to watch. OK – that’s about as much introspection as I can muster. On to the regular report.
Starting week 3 of the second chemo cycle. So feeling a bit better. The last two weeks have been dominated by an intractable cough. Some of it may have been due to spring and allergies. Some of the cough triggers may be coming from a chemo-weakened sphincter muscle in the esophagus – the one that holds back acid reflux. The reflux can trigger more coughing. And then I caught an old-fashioned cold. Among all three reasons, the cough was pretty vexing – poor sleep, annoying to anyone close to me, and just another tiring exercise. The doctors and nurses tried a number of things, and sent me for X-ray (to make sure I wasn’t headed to pneumonia) and even a CT scan (to check something I never was quite clear on.) PepcidAC helps, along with typical cough meds. You probably know the old line – a cold will go away in 7 days, but if you see a doctor it only takes a week! It will be nice to be cough free. Otherwise I’m in that week 3 not feeling so bad part of the cycle. Round three comes on April 4.
Oh, and that extra CT scan. Some of the lesions are a bit smaller than the baseline before chemo started, but one at least is larger. The pleural effusion (fluid just outside the lung) on my lower right side is reduced somewhat. We haven’t actually talked to a doctor about these results – I just went to the hospital and got a copy of the report. The original plan was to have the third round of chemo, then a CT scan as a midway check on whether the treatment is effective. We’ll see if that is still the plan when I go in next Thursday. We also have a return visit scheduled with the sarcoma specialist up in Portland, after that midway CT. It just seems right to get his take on progress and prognosis. I’m not sure what our decision options will be at that point. We’ll face those and report on those as they confront us.