Author Archives: MPN Advocacy & Education

Updated MANIFEST-2 Data With Pelabresib/Ruxolitinib Support Paradigm Shift in Myelofibrosis

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Author(s): Kristi Rosa

May 31, 2024

The addition of pelabresib (CPI-0610) and ruxolitinib (Jakafi) led to a significant and durable reduction in splenomegaly, showed a trend toward reduced tumor symptom score (TSS) from baseline, and improved anemia and bone marrow fibrosis at week 24 vs ruxolitinib alone in JAK inhibitor–naive patients with myelofibrosis, according to updated data from the phase 3 MANIFEST-2 study (NCT04603495) presented at the 2024 ASCO Annual Meeting.1

As previously presented at the 2023 ASH Annual Meeting, the trial met its primary end point when a higher percentage of those who received the doublet (n = 214) experienced a 35% or greater reduction in spleen volume (SVR35) at week 24 vs those given ruxolitinib alone (n = 216), at 65.9% and 35.2%, respectively (difference, 30.4; 95% CI, 21.6-39.3; P < .001).2 The mean percentage change in spleen volume at week 24 in the pelabresib/ruxolitinib arm was -50.6% (95% CI, -53.2% to -48.0%) vs -30.6% (95% CI, -33.7% to -27.5%) in the ruxolitinib-alone arm.

When looking at all responders who achieved SVR35 response, the proportion who lost response at any point in the pelabresib/ruxolitinib arm was 13.4% and more than double in the ruxolitinib-alone arm, at 27.8%. When examining the criteria of loss of SVR35 response plus a spleen volume increase greater than 25% from nadir, this occurred in 9.3% and 14.8% of patients, respectively. Notably, SVR35 response was consistently higher with the doublet vs the monotherapy across all predefined subgroups and across hematologic subgroups.

A strong trend for numerical decrease in absolute change in TSS from baseline at week 24 was observed with the doublet vs the monotherapy, at -15.99 and -14.05, translating to a mean difference of -1.94 points (95% CI, -3.92 to 0.04; P = .0545). A higher proportion of patients who received the combination vs ruxolitinib alone achieved a 50% reduction in TSS (TSS50), at 52.3% vs 46.3% (difference, 6.0; 95% CI, -3.5 to 15.5; P = .216); this difference did not reach statistical significance. A two-fold increase in patients who achieved both SVR35 and TSS50 responses was observed with pelabresib plus ruxolitinib vs ruxolitinib alone, at 40.2% and 18.5%, respectively.

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Azacitidine Plus Ruxolitinib Demonstrates ‘Promising’ Efficacy in Myelofibrosis

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Amber Denham

05/31/2024

Azacitidine in combination with ruxolitinib demonstrates promising efficacy for patients with myelofibrosis (MF), according to long-term follow-up results from a phase 2 clinical trial presented at the 2024 American Society of Clinical Oncology (ASCO) Annual meeting.

The trial included adult patients aged ≥18 years with MF intermediate 1 to 2 or high-risk disease, measured by the Dynamic International Prognostic Scoring System (DIPSS). From March 2013 to October 2021, a total of 61 patients were treated in the trial. Patients had a median age of 66 years (46 to 87). The median hemoglobin was 10.1 g/dl (6.8 to 16.2) and bone marrow blasts 2% (0 to 14%). Overall, 14 (23%) patients had BM blasts ≥5%. Furthermore, JAK2 was mutated in 35 (57%) patients and 38 (62%) patients had intermediate-2 or high-risk DIPSS disease.

Study results showed an International Working Group-Myeloproliferative Neoplasms Research and Treatment (IWG-MRT) response occurred in 44 (72%) patients. A clinical improvement was noted in 37 (61%) patients, including IWG-MRT spleen reduction >50% in 28 (61%) of 46 patients with baseline length ≥5 cm below left costal margin, and 31 (61%) of 51 patients with baseline total symptom score (TSS) >12 having a >50% improvement in TSS 50. In addition, a partial response was seen in 4 patients and cytogenetic complete remission in 3 patients.

With a median follow-up of 93 months, median overall survival (OS) was 46 months (95% confidence interval [CI], 25 to 66), median event-free survival was 33 months (95% CI, 24 to 43), and median duration of any objective response was 43 months (95% CI, 24 to 62). It was noted that disease transformation to AML occurred in 14 (23%) patients with a median time to transformation of 19 months. In addition, 20 (33%) patients received a stem cell transplant (SCT), and 11 (55%) patients had intermediate-2/high-risk DIPPS disease. It was observed that patients in the Intermediate-2/high-risk DIPPS group who received a SCT showed a trend towards improved median OS vs those who did not receive a transplant (38 vs 27 months, P = .2).

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Advances in Interferon Therapy for Myeloproliferative Neoplasms

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Kumar Das, Dibash PhD

Oncology Times 46(6):p 1,14, June 2024. | DOI: 10.1097/01.COT.0001024068.38723.15

In the ever-evolving landscape of myeloproliferative neoplasms (MPNs), clinicians continue to explore and refine treatment strategies to improve patient outcomes. A recent review published in Therapeutic Advances in Hematology sheds light on the pivotal role of interferons, particularly pegylated formulations, in managing MPNs effectively (2024; doi: 10.1177/20406207241229588).

The advent of pegylated interferons, including peginterferon alfa-2a and ropeginterferon alfa-2b-njft, marks a significant turning point in MPN therapeutics. These agents, renowned for their potent immunomodulatory capabilities and profound impact on disease progression, have reshaped treatment paradigms outlined in the National Comprehensive Cancer Network (NCCN) Guidelines for polycythemia vera (PV), essential thrombocythemia, and primary myelofibrosis. This article delves deep into the multifaceted influence of pegylated interferons, shedding light on their efficacy, safety profiles, and future implications in MPN management.

Clinical trials, including landmark Phase II and III studies such as MPD-RC 111 and MPD-RC 112, have provided crucial insights into the efficacy of pegylated interferons. These trials meticulously assessed response rates, molecular remissions, and hematological improvements in MPN patients resistant to or intolerant of hydroxyurea. Noteworthy reductions in JAK2 V617F variant allele frequency (VAF) have underscored the molecular response achievements of pegylated interferons, highlighting their disease-modifying potential.

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Predictors of symptom scores in myeloproliferative neoplasms: A real-world retrospective cohort study

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Muhammad Ali Khan, Syed Arsalan Ahmed Naqvi, Irbaz Bin Riaz, and Jeanne M. Palmer

Abstract

Background: Although high symptom burden indicates poor survival and informs treatment decisions, little is known about the impact of demographic, clinical, and laboratory features on total symptom score (TSS) in patients with myeloproliferative neoplasms (MPN).
Methods: Patients with MPN (polycythemia vera (PV), essential thrombocythemia (ET), and myelofibrosis (MF)) were identified from the retrospective chart review. TSS, individual symptom scores (fatigue, early satiety, abdominal discomfort, inactivity, concentration problems, fever, night sweats, itching, bone pain, weight loss), demographic characteristics (race, ethnicity, age, gender), clinical features (time since diagnosis, depression status, obesity status, spleen size), laboratory results and season at the time of visit were recorded from the clinical encounter when index assessment of TSS was performed for each patient. Normality was assessed using visual inspection of data distribution, whereas multicollinearity was assessed using various inflation factors. A univariable regression followed by a multivariable regression analysis was conducted using a backward selection approach. A p-value <0.05 indicated a statistically significant association of a given feature with TSS.
Results: The chart review identified 252 patients (PV: 78; ET: 81; MF: 93). Mean age was 59 (SD: 17.7), 67 (SD: 13.0), and 68 (SD: 10.9) years for ET, PV, and MF respectively. Most patients were white (PV, MF: 92%; ET: 83%) and females (ET: 75%; PV: 60%; MF: 53%). The TSS of patients was highest with PV (mean: 18.5; SD: 16.9) followed by MF (mean: 18.1; SD: 15.4) and ET (mean: 14.3; SD: 15.9). Fatigue was the most reported symptom whereas the least reported symptoms were fever and weight loss. Univariable regression analyses showed depression (B: 17.7; p=0.02), female gender (B: 10.6; p=0.01), platelet count (B: 0.03; p=0.03), and hemoglobin (Hb) (B: -2.6; p=0.01) in PV patients, depression (B: 19.8, p=2×10-5) in ET patients and depression (B: 11.0, p=0.03), white blood cell (WBC) count (B: 0.2; p=0.01), neutrophil count (B: 0.3, p=0.01), and non-neutrophil WBC count (B: 0.6; p=0.02) in MF patients to have significant association with TSS. Multivariable regression analyses (Table) showed Hb (B: -2.5; p=0.01) and platelet count (B: 0.02; p=0.03) in PV patients, depression (B: 19.7; p=2×10-5) in ET patients and depression (B: 12.3, p=0.01) and WBC count (B: 0.3; p=0.002) in MF patients to have a significant association with TSS.
Conclusions: Depression in ET and MF and low Hb in PV were identified as significant drivers of symptom burden. Identifying and managing patients with these comorbidities could improve their quality of life with a potential survival benefit.

Patient reported outcomes among U.S. Veterans living with myeloproliferative neoplasms

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Authors: Natasha Mathur, Andrew Chua  Tiu, Ann Brazeau, Natalie Giocondo, Puneet Gill, Shanshan Liu, Guoqing Diao, Ramesh Subrahmanyam, Craig M Kessler, and Maneesh Rajiv Jain

Abstract

Background: Myeloproliferative Neoplasms (MPNs) profoundly affect patients’ well-being, necessitating effective symptom relief. Patient-reported outcomes are pivotal for care improvement, aligning with Centers for Medicare and Medicaid Services priorities. This study aims to assess MPN symptom burden among U.S. Veterans, examining risk levels, thrombo-hemorrhagic complications, medication use, information access, care, and service-connected benefits.
Methods: Conducted as a cross-sectional survey from December 1, 2023, – January 22, 2024, all Veterans in the MPN Advocacy Education & International database were recruited. Symptom burden was assessed using the validated MPN Symptom Assessment Form Total Symptom Score (MPN SAF TSS), with descriptive statistics and T-tests employed for analysis.
Results: Of 61 respondents, 88% were male, 92% Caucasian, 88% served during the Vietnam war. The mean age was 73±7, with MPN diagnosis at 64±9 and a mean duration of 44±10 years from service-connected exposure. Key findings included 56% Polycythemia Vera, 26% Essential Thrombocythemia, 16% Primary Myelofibrosis, 70% JAK2, 10% CALR, 3% MPL, 14% unaware of their mutation status, and 34% unaware of MPN risk status. Seventeen (28%) underwent phlebotomy, 64% used Hydroxyurea, 29% Ruxolitinib, and 3% Interferon. Fatigue and itching were the predominant and severe symptoms (Table), with 43% reporting no symptom improvement. Mean MPN SAF TSS of all respondents was higher than prior study by Emanuel et.al. which adjusted for MPN subtype (36.4 vs. 21.6, p<0.0001). Twelve (20%) reported bleeding and 10% reported venous thrombosis after MPN diagnosis, while 13% reported arterial thrombosis before MPN diagnosis. Twenty-two (36%) are not seeing an MPN specialist and 61% are not seeing a hematologist at their local Veterans Affairs Medical Centers. Twenty-three (38%) did not seek a second opinion while 43% do not have a caregiver. Respondents turn to MPN organizations (75%), physician offices (74%), Google Search (49%), Webinars (41%), and Facebook (23%) for information. Five (8%) received service-connected disability benefits.
Conclusions: Veterans with MPNs endure a substantial symptom burden, surpassing previous studies, signifying suboptimal management. Limited access to care persists, necessitating enhanced support. However, self-reporting bias and potential limitations in activity assessment must be acknowledged. Efforts to enhance MPN awareness, specialized care, and support mechanisms are imperative for comprehensive management.

MPN Word of the Month: Cytokines

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MPN Word of the Month:

Cytokines

Recently, I heard someone describe cytokines as ingredients that make up a recipe. The recipe is a response to a specific event. Like, when we make chicken soup when someone we love has a cold. Each person with an MPN has their own special ingredients that come together in  response  to different events that happen inside and outside of the body. 

So what are cytokines, really? Cytokines are tiny proteins secreted by cells to communicate with one another.  What do they say? Basically, they say to activate (go from doing nothing to doing something), proliferate (make more cells), or differentiate (become more specialized, like becoming an eye cell or a liver cell).

Cytokines can send messages to increase inflammation (pro-inflammatory), or stop inflammation (anti-inflammatory). Inflammatory cytokines play a role in the development and progression of myeloproliferative neoplasms. 

Some research suggests that there are certain cytokines commonly associated with MPNs. For example, IL-1β (Interleukin-1beta), TNF-α (Tumor Necrosis Factor-alpha) , IL-6 (Interleukin-6), IL-8 (Interleukin-8), VEGF (Vascular Endothelial Growth Factor), PDGF (Platelet Derived Growth Factor), TGF-β (Transforming Growth Factor-beta), and IFNs (Interferons). These cytokines are expressed in different ways that may contribute to the various MPN subtypes. 

For example, a recipe may call for tomatoes, but there are different kinds of tomatoes based on their individual genetic makeup…Roma tomatoes, San Marzano tomatoes, Cherry tomatoes. This recipe (cytokine expression) can be seen in different subtypes. For example, people with polycythemia vera (PV) have been known to have elevated levels of IL-12, IL-4 and GM-CSF when compared to people with essential thrombocythemia (ET). Some cytokines, such as BLC, Eotaxin-2, M-CSF, and TIMP-1, may one day help diagnose and predict the progression of fibrosis in MPN subtypes. 

While it is not completely clear how your cytokine “recipe” can be affected by lifestyle, conventional wisdom tells us that healthy lifestyle changes can’t hurt. Reducing additional inflammation that may occur through lifestyle choices could help to support your body in ways that impact your experience of your symptoms at the least. A healthy diet, exercise, and stress reduction have all been associated with lowering inflammation in the body. 

A Patient’s Story: Perseverance and Advocacy

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Julie describes her PV journey as one that was initially filled with confusion, anxiety and an unclear path. In 1997, just 6 months after her father passed away from Non-Hodgkin’s lymphoma, abnormal lab results and her recent family history prompted her doctor to perform a bone marrow biopsy. At just 26 years old, she didn’t think twice when the biopsy was all clear and she was given a clean bill of health. 

Years later, an athlete and competitive mountain biker, Julie’s body suddenly refused to cooperate. After a noticeable change in her performance, she went to the doctor again. This time the doctor ordered a series of tests…and then an ultrasound…and then a heart catheterization. Her healthcare team had assured her, she was young, she was thin, she was in shape, she had no family history of heart problems, she was probably fine. Boy, were they wrong! Julie  had a 90 % blockage in her left anterior descending artery. Now, in her 30’s, she was told she would need a stent. What, no way?! she was on her way to Miami Beach with her friends, she had a bikini all picked out,  she was not doing surgeries and stents and hospitals. But that is exactly what she did. And afterwards, she felt amazing. 

This is where we have to stop and ask ourselves, why would a young woman with no family history of heart problems, who was thin, fit and otherwise well have this kind of episode? Well, the doctors didn’t know, so they labeled it coronary artery disease, told her to cut back on salt and sent her on her way. 

In 2008, Julie was racing motorcycles and working 60 hours a week. She was in charge of a large software roll out at the company she worked for…but something was off. In one week, her stomach was swollen, she lost her appetite, and when she did eat she was full almost immediately. By day four, she was so uncomfortable she couldn’t sleep, that’s when she headed to the ER. A percussion test revealed that her abdomen was filled with fluid (ascites) and they drained 2.2 liters that night. After being poked and prodded, they admitted her to the hospital and though perplexed, felt she may have ovarian cancer. The next six weeks were filled with various bouts of internal bleeding affecting multiple organs and bouncing in and out of the hospital, mostly in. It turns out, she had a serious clot in the hepatic vein that runs from the liver to the heart. Her liver was being strangled and “sweating like a quart of milk.” Not only was Julie unwell, but she was out of work during a pivotal moment for her company and her career. She felt as though was letting a lot of people down by being sick. 

At this point, she had a team of doctors who reviewed her medical records for the last 15 years. Enter the young, vibrant (and I would like to imagine) attractive doctor with a brand new Jak2 genetic blood test. The results? Julie was positive, and so were her doctors.  After a decade-long medical odyssey,  Julie was formally diagnosed with Polycythemia Vera. Another member from her medical team  told her, “Your life as you know it is over. You ride motorcycles, forget that, you’re not doing that. You’re 38, well you won’t have kids because you’ll have  a high-risk pregnancy. You are going to be on blood thinners for the rest of your life..” And the list went on. 

“You have to be feeling down, and then notice that if you start feeling more down, it takes twice the work to get back up again. And that’s what PV has taught me, so it’s not avoidance [of getting down] it’s more about where I am going to look? I learned that from motorcycling, wherever you look, that’s where you go.” Once stabilized, she walked out of the hospital, and looked up at the moon for the first time in 6 weeks. She felt lucky that she was even able to walk out of the hospital, some people were not. 

She said she has learned to sit with the fear, anxiety, and frustration when they creep up instead of running from them. But she doesn’t stay there, “you can go cry in your room, but you can’t just stay there and die.” Julie remembers that people usually die with PV, but not from it and that she is living with cancer. 

How did she cope? She started keeping track of how she felt each day. She was forced to get better at listening to her body. After a while, she saw patterns emerging and associations between her feelings and her lab work. For example, when her hematocrit spikes her scalp gets itchy and her fingertips get red. When this happens she knows it’s time for a phlebotomy. The more she knew about herself, the more she felt she was able to take care of herself, and that confidence reduced her anxiety. From there, she was able to start talking to the people around her about what she was experiencing and what she needed. She was even able to begin to direct her medical team, sharing with them important associations and symptoms that they could use to make better decisions about her treatment together. 

Four years after her diagnosis, Julie and her husband welcomed their son into the world. Pregnancy suited her, and her PV. Not only did she become a mom, she also became a mentor to MPN patients. She said that what she went through, and what she still goes through is more purposeful if she can share it to help someone else feel less afraid, less isolated, and less confused. 

Julie emphasized that PV has been and continues to be a journey, she hasn’t arrived, the journey is still in process. She said, “PV is the gift I didn’t want because it made me more grateful for the life I have, more aware of the people around me, more open to the world and its beauty…and it didn’t start out that way.”

If you want to learn more about Julie’s journey you can see her talk about her story on Facebook or read more about her at Woman’s Day. She also did a quick video about itching and is available to connect with other patients at  pvmamawarrior@gmail.com.

Childbirth rates in women with myeloproliferative neoplasms

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Published March 9, 2024

Anna Ravn Landtblom, Therese M-L Andersson, Anna L. V. Johansson, Frida E. Lundberg, Jan Samuelsson, Magnus Björkholm & Malin Hultcrantz

Abstract

Myeloproliferative neoplasms (MPN) are associated with inferior pregnancy outcome, however, little is known about fertility and childbearing potential in women with MPN. In this study we aimed to describe reproductive patterns, as well as to quantify risk of miscarriage and stillbirth. Women aged 15–44 years with an MPN diagnosis 1973–2018, were identified in Swedish health care registers, and age-matched 1:4 to population controls. We identified 1141 women with MPN and 4564 controls. Women with MPN had a lower rate of childbirth (hazard ratio [HR] with 95% confidence interval was 0.78 (0.68–0.90)). Subgroup analysis showed that the rate was not significantly reduced in essential thrombocythemia, HR 1.02 (0.86–1.22) while the HR was 0.50 (0.33–0.76) in PV and 0.45 (0.28–0.74) in PMF. The risk of miscarriage was not significantly increased before MPN diagnosis, the HR during follow-up after diagnosis was 1.25 (0.89-1.76). Women with MPN were more likely to have had a previous stillbirth. Women with MPN had fewer children at diagnosis, and fewer children in total. In conclusion, the childbirth rate was lower among women with MPN than controls, but not among women with essential thrombocythemia.

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A Review About the Assessment of the Bleeding and Thrombosis Risk for Patients With Myeloproliferative Neoplasms Scheduled for Surgery

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Mihaela Andreescu
Bogdan Andreescu

Published March 12, 2024

Abstract

Myeloproliferative neoplasms (MPNs) present a unique challenge in surgical management due to their inherent predisposition to both bleeding and thrombosis. MPNs are a heterogenous group of acquired clonal conditions. The three classic MPNs are essential thrombocythemia (ET), myelofibrosis (PMF), and polycythemia vera (PV). All subtypes of MPN are associated with both thrombotic and bleeding complications. There are four risk categories for thrombosis in MPN patients: age, thrombosis history, and JAK-2 mutation. They are further classified as very low, low, intermediate, and high risk. The genetic landscape of MPN is fascinating and complex like all myeloid disorders. Bleeding risk can be assessed through leukocytosis, thrombocytosis, acquired von Willebrand syndrome (AVWS), and a previous history of bleeding in a patient. Risk assessment and perioperative management are important aspects of improving the quality of life and preventing complications in surgeries. Preoperative management includes a risk assessment of venous thromboembolism, use of appropriate pharmacological treatment, platelet count control, and correction and cardiovascular risk factors. This review summarizes the assessment of bleeding and thrombosis risk for patients with MPNs scheduled for surgery. Furthermore, this review discusses various tools that can be used to identify MPN patients at risk of thrombosis prior to surgery.

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A Patient Story: Living 32 Years with an MPN

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By Ron K.

Fortunately, my MPN journey has been a long one. I was first diagnosed 32 years ago and I know have post-Polycythemia Vera Myelofibrosis. Looking back it was almost archaic in nature. Today the progress has been immense on many fronts, not just in treatment, but with treating the patient as a whole. As many of you know, there is no exact recipe book for life with cancer and its treatment journey is unique.  My hope is that sharing some of my experiences may help someone else along the way.

There is a quote by Albert Einstein that reflects my approach to my medical journey

Learn from yesterday, Live for today, Hope for tomorrow. The important part is to not stop questioning.

Learn, Live, Hope – three good words for any cancer patient.

As those with an MPN know this is a chronic neoplasm and unfortunately there is no treatment yet to cure this illness. Some of the latest MPN and MF drugs do improve one’s quality of life and even appear to extend one’s survival, a significant milestone from what was available just a handful of years ago. Finding ways to slow or stop the progression is my only hope until medical knowledge can surpass me with a real solution.

Having a chronic cancer and having it for a long time has enabled and encouraged me to evolve into a healthier lifestyle. One does not have to change everything overnight but just evolve and continue to build healthier ways, one step at a time. While there is no evidence that a healthy lifestyle will cure me, it is something I can do and have control over.

This all started back in 1985 when I went to my family doctor with a cold and I mentioned that my colds seem to last longer and hit me harder than others.  A simple blood test began my journey.  I would not be alive today if I followed my first hematologist’s treatment plan. He wanted to treat me in a traditional manner at that time, with a radio isotope that kills off some of the marrow, they know now that treatment leads to an acute leukemia years down the road. Instead my intuition questioned this approach, since I was only 31 and I thought that I might need that marrow later in life.  I called a major metro medical center and asked for an appointment with their Chief of Hematology. Unknown to me at the time, and not commonly termed in the 1980’s, I was going to get something called a second opinion. I got an appointment and his approach was quite different. He wanted to understand me, my rate of progression, severity, etc as that would lead him to figure out how to best treat me. He even commented that the current radio isotope treatment (my first hematologist’s plan) to kill off marrow was likely going away as he saw it.

Today, I am a patient of Dr. Mesa’s. I found that they could answer all my questions. Answers to questions that my previous hematologists could not answer. They have knowledge that is very leading edge as to direction of MPN treatments as they are part of an elite group of hematologists that are making many of the MPN discoveries, designing the clinical trials and studies with other key hematologists around the world.  So my personal doctor advice is to make sure you find the right doctor and treatment strategy for you. Listen to your intuition and ask questions, seek information and acquire knowledge in your cancer and health. Expect answers or find those professionals that can give them to you. While I did not need a MPN specific doctor early on I do need one now as I am living well beyond the averages.

For me, finding the right doctor has been a key in my cancer treatment journey. Getting a second opinion is also key. What you will likely find is the different doctors will agree on the diagnosis but their treatment strategy will often be different.

I attend conferences, seminars, and special programs such as those that the MPN Advocacy and Education International puts on. I have done online webinars or conferences as well as belong to online MPN listing groups to learn and share information. I find this information to be helpful to ask the right questions to my doctors and understand what may be option in the future.

I believe support makes a difference. It is helpful to have support from your spouse, kids, parents or friends. I also find that support groups can be very helpful as well. As they can fill a support void that is missing from one’s non-cancer family and friends. This is no fault of family, spouses, or friends in that they do listen and they do try to understand and relate and they do support the cancer patient, but I have found that belonging to a cancer support group often helps to fulfill things non-cancer patients cannot quite grasp. I have belonged to both hematology specific support groups and all cancers support groups. You might want to try both and see if one works better than another.

 

As I live my life, I am grateful for every day. Everyday is a great day, just some are even better than others.  I even celebrated the point in my life where I have lived longer with cancer as part of my life than without cancer. That was at about 31 1/2 years and I had a bakery make me a cake to celebrate the occasion. The cake was symbolic of my MPN journey and view of life. I celebrated this occasion with my all cancer support group. So while cancer is a part of my life I run my life with cancer being a part of it and I do not let my cancer rule over me.  I am hopeful that a cure is in our much sunnier MPN journey. May the best be yet to come, and enjoy the day!