Halfway is Almost There

Halfway is Almost There

A New Prognostic View for Diffused Large B-Cell Lymphoma Survivors

Several weeks ago my wife and I were running on our local bike trail and came across one of her friends. The friend asked how I was doing with my fight with cancer and I replied that my recent PET scan showed I have now been cancer free for two and a half years. She said, “That’s wonderful, you are halfway there”. For many cancers, like mine, if one survives cancer free for 5 years you are considered cured. Making it 5 years is a key milestone for most cancer patients. So measured in time I am halfway to being cured. However, by looking at it in a different way, by risk or probabilities, I am almost there.


When I was first diagnosed with aggressive cancer I was giving a probability of about 50% of making it 5 years and being cured. That scared the hell out of me. I would have preferred something like the 90% chance they give to Hodgkin’s lymphoma patients. Since my first diagnosis my oncologist doesn’t speak in terms of probability or numbers. He just says, “You are doing great”, or “it couldn’t be better”. Now, I don’t think I’m the only cancer patient that would like to hear quantitatively what my chances are of being cured, especially if those chances have improved over time. What if you had an accountant take care of your finances and during an annual review of your finances your accountant says, “You are doing great”. Would you be happy with that and no numbers? I don’t think most people would, they would want to know how much money they have in the bank.

I researched the internet for an answer. I looked at all the reputable cancer websites(1) and through many published medical papers on cancer survival studies, but they all show the same thing, survival probabilities for cancer patients who have been just diagnosed. Figure 1 below shows an example of such a plot. I obtained the data for this plot from a medical paper published on a study made in British Columbia.(2) The plot is the overall survival (in percent) of 365 patients with diffuse large B-cell lymphoma (DLBCL), the type of cancer I have. The way to read the plot is first pick a time on the horizontal axis, draw a vertical line until it reaches the curve, then at that intersection point draw a horizontal line to the vertical axis and read off the probability of surviving that period of time. For my disease, the probability of surviving 5-years is just under 70 percent, which means out of 100 patients, 70 of them will be still alive after 5 years from diagnosis.

Figure 1. Overall survival of patients diagnosed with diffused large B-cell lymphoma.

From the plot in Figure 1 you can see the importance of 5 years. The curve is flat from 3.5 years to beyond 5 years, whereas the period from 0 to 1 year the curve is very steep. That means during the first year patients are lost very quickly, whereas after 3.5 years and beyond there were no patients lost to the disease. There are survival plots that go way beyond 5 years and they show that after 5 years it is rare that a patient is lost to the disease. Therefore making 5 years typically means your risk of dying from the disease is pretty low, and it’s time to be concerned of other things like car accidents or being struck by lightning. The problem is that these plots are only directly useful for recently diagnosed patients.

After some thought I got an idea that maybe I could take the published 5-year survival data for recently diagnosed patients, and convert it to data that shows probability of surviving 5 years based on how long one has already survived. That would take an equation that I would have to derive from some basic principles of probabilities. I won’t bore you with the theoretical details, but just in case you are interested you can read it later in the Appendix of this post. The equation I derived (see Equation 1 below) takes values from a survival rate like the one shown in Figure 1, and gives the probably of surviving 5 years based on how long one has already survived after diagnoses. In the equation P0(t=5) is the probably point read from the plot at 5 years and P0(t) is the probability point read at t years, where t years is the number of years one has already survived. P5(t) is what I call the Running 5-year survival rate, and is the probability of surviving 5 years based on how many years one has already survived since first diagnosis.

          (1)

Figure 2 shows two curves based on data taken from the British Columbia paper on survival of DLBCL patients. The red curve is for all patients in the study, and the blue curve is for patients that meet a certain criteria – patients whose cancer was found in its early stages. Fortunately I happen to be in the better group. The way to read this plot is look up how long you have survived since diagnosis on the horizontal axis, draw a vertical line up to the curve, then at the intersection draw a horizontal line to the vertical axis and read off the probability of surviving to 5 years. I’ve drawn lines for myself at 2.5 years and you can see I now have about a 96% chance of surviving 5 years. However, notice at 3 years, my probability is 100%. I’m almost there! I’m almost to the point of being cured. Now I fully understand when my doctor says, “It couldn’t be better”.

Figure 2. Running 5-year survival rate based on years survived after diagnoses of diffused large B-cell lymphoma.


You have to be a little careful using these charts. For example, the fact that the blue curve in Figure 2 is at 100% after 3 years does not mean the TRUE probability of survival is 100%. It just means that after 3 years, the remaining survivors of the original 365 patients in that particular study didn’t die after 3 years. Science tells us that if we included many more patients in the study, say 10,000 patients or 100,000 patients, we would find that the blue curve will never go to exactly 100%. There is always some risk of the disease coming back. However, when the probability of surviving gets up to somewhere near 99%, one is doing very well, especially when you consider that about 1-in-4 males and 1-in-5 females will eventually die from some type of cancer.(3)

I’m excited about this. I find much more comfort in knowing quantitatively that my survival chances are so good and that nearly all the risk is gone after three years, not 5 years. My three year PET scan will be in March 2011, just before my 52nd birthday. There’s no 100% guarantee I’ll have a clean PET scan, but there are good reasons, scientific reasons, to be very hopeful. Whatever happens in the future, there is one absolute guarantee, I will thoroughly enjoy life to it its fullest.

Appendix

The following are some simple mathematics with statistics. The probability in percent P0(t) of surviving t years after diagnosis is defined as

          (2)

where N(t) is the number of survivors at time t, and Np is the total number of patients at diagnosis in the study. What we want to know is the probability of surviving 5 years based on the number of years already survived (P5(t)) after diagnosis. P5(t) is defined as

        (3)

where N5 is the number of survivors at 5 years and N(t) is the number of survivors at time t. So the probability of surviving 5 years after already surviving t years is the number of patients that have survived 5 years divided by the number of patients that have survived t years. Multiplying by 100 puts the probability in terms of percent. By combining Equations 2 and 3 and doing a little algebra we find that P5(t) can be expressed in terms of two probabilities,

          (4)

which can be read directly off the published graphs and we do not need to know the actual number of patients in the study.

To accurately obtain values from published graphs, I use a trick that involves Microsoft PowerPoint software. I use the Print Screen keyboard key to copy an image of the graph into the Windows clipboard; then I paste the image into PowerPoint. I create a PowerPoint circle object and place the center of the circle over a point on the graph that I want to record location values. Within the Format AutoShape tool I click on the Position tab and read the horizontal and vertical position of the little circle. These are coordinate values from the PowerPoint coordinate system. I enter the coordinate values into an Excel spreadsheet and repeat the process until I have enough points that accurately represent the curve on the graph. The points from the PowerPoint grid coordinate system must be converted into the graph coordinate system. To make the transformation I record a couple of points from each of the graph axes into the Excel spreadsheet where the transformation from one coordinate system to the other can be made with the appropriate equation. Once I have the curve values into Excel I can then apply my equations to manipulate the data and create my own plots.

References

(1) www.mayoclinic.com/health/cancer/CA00049

(2) Laurie H. Sehn, et. al. ,”The revised International Prognostic Index (R-IPI) is a better predictor of outcome than the standard IPI for patients with diffuse large B-cell lymphoma treated with R-CHOP”, www.bloodjournal.org, October 5, 2010.

(3) www.cancer.org/Cancer/CancerBasics/lifetime-probability-of-developing-or-dying-from-cancer

Two Years is Worth Everything

Two years ago when my oncologist was giving my wife and me the possibilities for my future, I was shocked when he expressed contentment that chemotherapy could extend my life a couple of years. That was really disturbing to me. I wanted much more than two more years, especially if I was going to go through the agony, suffering and potential lethal risks that chemotherapy can dish out. Thinking that my oncologist was being conservative with his bedside manner, I searched the internet for more optimistic news, but everywhere I looked the message was the same, two years, even several months of extended life was considered worth doing the most dangerous medical procedures. Now it’s been about two years after my diagnosis of cancer and I now know the truth – life is worth every bit of struggle.

These last two years I have lived a lifetime. I’ve ran two marathons, a half marathon, and my wife has joined me on shorter races. We’ve been on many trips these last two years. My wife and I had a romantic wedding anniversary in Las Vegas. My wife and two boys have gone to the Minnesota Boundary Waters for a canoe adventure, a trip to Arizona and Las Vegas, and a road trip to Arkansas to my in-law’s cabin in the Ouachita Mountains. My two boys and I went with other family members on our first Huck Finn trip, canoeing down the Mississippi River along with the barges, and camping on sandbars. My wife traveled with me on a week long business trip to Phoenix while Grandma and Grandpa watched our boys. There were snowboard outings and countless family gatherings for birthdays and holidays and special family annual get-togethers like the Strandjord Winter Lutsen gathering on north shore of Lake Superior and the Strandjord Fall Wiener Roast at my parents place in the country.

During these last two years I’ve seen my granddaughter catch her first fish, my grandson shoot his first real gun. I saw my daughter move to Manhattan all on her own and land a job as an assistant to a COO of a hedge fund during one of the most difficult times in the job market and economy. I saw my oldest son, who’s a senior this year, make the All Conference Team in high school bowling by ranking 7^th in the conference. At the conclusion of the season he was ranked 81^st in the state. I saw my youngest son blossom in wrestling to become a captain of his middle school team and go undefeated during regular season. This year he is wrestling on the high school team and has wrestled both JV and varsity. Two years ago I was hoping to live just long enough to see another bowling and wrestling season.

Just after finishing chemotherapy I joined my wife in riding Harley’s. My wife has been a Harley biker for many years and has her own Super Glide. I bought my Fat Boy while still going through chemotherapy. When I was going through chemo and fighting cancer I didn’t put my dreams and aspirations on hold. That really helped me stay positive during those difficult times. Since then my wife and I have gone on many rides. We like head out with little planning and see were some country roads take us. As we explore the countryside we look for that special biker bar in some little town to have a hamburger and ice tea. Over these last two years biking has become a very important part of my life, and what makes it extra special is I get to enjoy it with my wife.

Those were the major highlights of the last two years and this article only takes a slight glance at them. To really convey the wonderfulness of each would require a novel to describe the sights, the sounds, the feelings, the smiles and laughter that make up each one. When you break down a life highlight into the constituents that really make it wonderful you find those elements that also make up any ordinary day. When I look back at these last two years I see a lifetime of those elements: smiles and laughter with my family, my wife snuggling to me while I hold her in my arms, my youngest son snuggling to me while we watch TV, my granddaughter giving me a leg hug while she says, “I love you grandpa”, and it goes on and on and on.

Now I get it. Now I understand why physicians show high spirits when there is a chance of extending someone’s life a few months or a couple of years even if it means undergoing a dangerous procedure; because every minute of life is worth every bit of struggle. All it takes is one minute to feel joy from a smile, a hug, a laugh, a sound, a sight, a smell or a few simple spoken words. There’s about 43,000 minutes in a month, and over a half of a million minutes in a year. That can add up to a wealth of hugs, laughs and smiles.

Friday the 13th, In Your Face!

Friday the 13th my wife and I were escorted by a nurse to exam room #13. “Is the universe trying to tell me something”, I thought. It’s Friday the 13th and I am in room #13 about to here from my oncologist about my recent PET scan results. The nurse did ask if I wanted to change rooms, but I figured if there was such a thing as fate, it was already sealed for that day and changing rooms wouldn’t suddenly change the outcome of my visit. Honestly, I don’t believe in superstition and fate. Well, in your face Friday the 13th, my PET scan came back perfect – absolutely no cancer. Of course, my great results were not just random luck, I had a little influence.

So far two of my PET scans came back positive for cancer activity, but later proved out to be just inflammation of scar tissue where I had surgery. It’s not a good day when your oncologist says, “Your scan has shown in uptake, it is probably nothing, but it does indicate that the cancer is coming back and we need to watch it very closely and have you come back in a few weeks for another scan”. I reason, for good reasons, my active lifestyle with long distance running is causing my hernia surgery site to be inflamed and not to worry about it, but it still can rest heavy on the mind. So I found a way to combat it, with ice!

I figure if ice is good for reducing swelling and inflammation of sports injuries, then why not old hernia surgery sites. So about 3 days before my PET scan I start applying an ice pack to my groin each night, and oh that’s cold. That doesn’t sound like much fun does it? It beats the alternative, going through weeks of anxiety until another PET scan shows that the cancer is not coming back. Every time I have used ice packs before a scan my scan results have come back negative. Earlier this year I got lazy one time and didn’t use ice packs and sure enough, the PET scan came back positive. Now I’ll do anything to make sure I use the ice treatment.

This last week I got lazy again, waiting to the last night before my scan before using ice packs. That night I went to my parents, which is about an hour drive from my home, to visit and help out with a few things. I didn’t want to stay up late at night, so I employed my technique on my drive back home. It was good I wasn’t pulled over by the police. It would have been uneasy trying to explain why a bag of ice was stuff down my pants.

It’s amazing that we spend a lot of effort dodging superstitions, yet many times we’ll do little or nothing of the things that really have control in the outcome of our lives.

PET Scans, Diets, and Mountain Training

Well I have some fabulous, fantastic, super, wonderful, amazing, awesome, tremendous, astounding, splendid, breathtaking, great, extraordinary, remarkable, magnificent, huge, enormous, very big, terrific, superb, marvelous, brilliant, spectacular, astonishing, good news. My PET scan came back squeaky clean again. My Oncologist is very impressed. In the past when asked about how he felt about his pathologist’s diagnosis (a curable type of lymphoma,) and Mayo’s diagnosis (an incurable type), he refused to give any speculation and just concluded it was a difference in opinion and there’s not much we can do about it. But now he is thinking a little differently. He still talks with great care. He is a well seasoned oncologist and knows how to talk to the patients without scientific backgrounds. I’m working on him to communicate in my language - science, math and probabilities. These are not the exact words he said, but rather my interpretation.

Being a seasoned oncologist, he has seen many cases of both types of lymphoma: diffused large B-cell (DLBC) and follicular. He has seen how patients of each type respond to chemo and that, on the average, there is big difference in response characteristics. I speculate that many more DLBC patients have rapid and complete responses than follicular patients. It may be rare that follicular patients have a complete remission that lasts any period of time. Therefore, since my response has gone so well and so complete, the probability that I have follicular lymphoma (incurable type) is low and it is much more probable that I have DLBC. We will never know for sure, but the more time I stay in complete remission, the more probable I have been cured.

Getting through the first year in complete remission is a huge milestone. At the one year milestone my odds of surviving and being cured are much greater than 50/50 odds I got just before starting chemo. (I intend to calculate those odds based scientific papers I found on the internet, but I’ve been too busy enjoying life). The first year milestone is the biggest for burning down risk, but the second year is a big one too. However, it doesn’t matter what happens here on out. I’m very gratified with the extension of life I’ve received thus far. From here on out, it’s icing on the cake.

Even though my diet and my training have not gone exactly to plan, my weight loss has. During the work week I do a pretty good job of staying under 2000 calories a day. But I haven’t been able to count my calories close enough to record them. It’s easy to measure food when I’m home, but whenever we dine out or eat at someone else’s house or when I’m on a business trip, I just have to estimate how many calories I eat. And I don’t always count them either. I have been traveling to Phoenix on business trips for the last couple of weeks, but that is a good thing when it comes to my diet. For business travel I don’t dine out but rather get a hotel suite that has a kitchen and cook my own food. Since I buy all my groceries, I don’t get the tempting treats that my wife gets for our sons. So I actually eat much healthier when I travel on business. I haven’t given up on calorie counting; it is still the basis for my weight loss plan. I’ll still do it when I can and when trying new meals. Many of my meals I already know how much to take to stay within my calorie limits.

Keeping track of my weight every day has also been a learning experience. I’ve noticed that my weight has a big cycle that repeats itself over a one week period. Every weekend my weight goes up 2 or 3 pounds, and then drops during the week. I think the weekend weight gain is mostly water weight. I speculate that on the weekends I tend to eat foods that are much higher in sodium, which can make the body retain water. So monitoring your weight on a daily basis can drive you crazy if you’re not careful with interpreting the data. The first plot of my weight shows my daily weight over four weeks. The first week I was not on my diet. During the fourth week I was in Phoenix so there is some missing data. You can see my weight being all over the map, but there does appear to be a downward trend too.

A better way to look at weight is by averaging the daily weight over a one week period. This takes out the weekly cycle and reduces random variations. As you can see in the second plot the data points fall much closer to the fit line, which shows that I’m losing on the average 1.2 pounds a week (rounded up), slightly better than my goal. The fit equation shows a good R^2 factor of 0.98 (rounded up) which means the data follows the fit line to a very high degree. Isn’t science amazing?

My running training has gone very well too, but not always as planned. Over the prior two weeks I have run two half-marathon (13.1 miles) runs. The first one I didn’t have a great finish time of 2:02, a long ways from my goal of 1:39. However, I was running mostly on my local trail which had fresh loose snow on top of ice. The slipperiness robbed energy from every step I took. I was exhausted and beat up near the end of the run and hoping it was due to the slippery conditions. The following week the loose snow had melted and I was mostly running on hard pack snow, in which my trail running shoes get pretty good traction. My finish time was 1:54 and I felt great at the end of the run. My guess is that my time will improve even more just from better traction after the snow and ice disappears this spring.

My weight loss plan included running at least 30 miles a week to burn roughly 3500 calories or more per week. Well that hasn’t worked out to plan either. The biggest deviation comes with business travel to Phoenix. Not because I don’t run, but because I do a different type of run while in the desert. My favorite kind of running is trail running, and my favorite trail running is in the desert, and my favorite desert trail running is up and down a mountain trail. I have read that some marathon coaches feel that hill training can also improve speed or finish times. Well, mountain training must be the best then, right? One of my favorite mountains to run up and down is Shaw Butte in the North Mountain Park of Phoenix. Going up the mountain I try to run as much as I can, but need to take walking breaks at the steepest part. There’s something about running up a mountain that is motivating and makes it easy to push harder than usual.

My favorite part though is running down the backside of Shaw Butte, which is very steep and rocky in places. It’s a type of meditation for me. Any mistake could lead to a serious injury, so one must keep constant and absolute focus on each step. This kind of focus really clears the mind of the daily garbage.

When I mountain trail run my running distances (about 4 miles) are less than the typical 6 miles I run on flat land. So it may seem that I’m burning fewer calories if going just by distance. However, based on time and heart rate, I think I’m burning more calories. There are websites that calculate how much calories you burn for just about any activity, including mountain climbing and mountain biking, but I haven’t seen anything on mountain running.

So my diet and running training have not gone exactly how I planned. I actually thought of giving up on my diet method. I’m kind of a perfectionist and have trouble finishing things that don’t go to plan. But this time I listened to the words of Winston Churchill, “never, never, never give up”, and decided to stick to my plan but adapt. I can’t stick to 2000 calories every day because many days I just don’t know how much I’ve eaten. But I keep working on learning how many calories on in each meal. I think it’s important to know what you eat. But that just doesn’t happen overnight. It’s like training for a marathon. You certainly don’t start out perfect; it takes a long time to get into a good routine. You’ll always have some bad days, some that you have control over and some that were self inflected. I think one of the key things to succeeding in anything is to realize that nothing including you is perfect and that perfection is not required to move forward. As long as you never, never, never give up, one step back and two steps forward will get you to your destination every time.

PET/CT Scan

I had a PET/CT scan this morning. Friday I’ll know the results. This is a very important milestone for me. If my cancer is still in complete remission I will have gone 13 months since the start of my chemo. For prognostics, such as survival rates, studies use the start of chemo treatments as day zero. Typically, my type of cancer takes one very quickly if it is going to take you. The highest chance of the cancer returning is in the first year after chemo has started. There still is significant risk during the second year, but a lot less than the first year. Not that I worry about it much, but it is nice to know my odds of surviving the next few years is much better than 50/50.

BWCA Photos

I went a bit crazy with posting 42 BWCA photos, but I had over 400 to choose from. Before going on I need to put this BWCA thing into context. Besides Grandma’s marathon, looking forward to a family adventure in the BWCA was instrumental in fighting off depression and despair during the time I didn’t know if I would be physically capable of such a thing, or worse yet, alive. It would have been easy to temporarily give up future dreams and concentrate on the task of fighting cancer and preparing my family for the worse. However I found that the best thing for me and my family was not to push future plans aside, but rather embrace them. My brother Cary stepped in by proposing a BWCA adventure.

Cary and I have done many adventures together, sometimes with our brother Mark and sometimes with other family members. In the last few years our adventuring has gone mostly to the wayside; life was way too busy. Then aggressive cancer threatened to swiftly take my life. That was a wakeup call to refocus on the truly important things. I wasn’t the only one to get this wakeup call, others close to me also benefited from my cancer. Yes, you heard it right - benefited. As horrible and ugly cancer is, there are also a lot of positive things that can be harvested from it. Cary and I are now planning other adventures, such as a backpacking trip into the Crazy Mountains and a sea kayaking trip from the Minnesota north shore of Lake Superior out to Isle Royal, an island in Lake Superior that is a national park and a primitive wilderness area.

On our BWCA adventure we canoed over 24 miles of water and portaged more than 4.5 miles in six days and five nights. My brother Cary and his wife Pat, being pros at this thing, could have covered at least twice that distance in the same time, but my wife Renee, my sons Chris and Daniel, and I are rookies and thus set the pace. Trying to cover as much distance as possible wasn’t on our docket anyways. Thanks to Cary and Pat we learned how to do things efficiently and comfortably. We saw other groups that were obviously rookies with no clue. The right methods can make the difference between flirting with disaster, misery and pain and having a fulfilling and enjoyable time. Besides, it just feels good to do things the right way. As you can see from the following photos, we had a wonderful time.



Preparing dinner at the Sawbill campground the night before our adventure.

Day 1: Cary and Pat find a quiet nook out of the wind while waiting for the rest of us to catch up on Sawbill Lake.

Renee and Chris unloading at our first portage at the northern end of Sawbill lake.

Daniel digs in with a paddle on Ada Creek. During this stretch we had to drag the canoes over a beaver dam.

Renee and Chris bring up the rear on Ada Creek. If you try to step out on the grass you'll find yourself sinking into waist high muck.

For the first day Cary and Pat take the lead, but after us rookies learned a few things, they let us lead the way for most of the trip. I think this is Ada Lake.

Daniel and I unloading the canoe to prepare for a 180 rod portage. This was an easy landing. For some landings I would have been over my head in water if on the outer side of the canoe.

I think this is Cherokee Creek. I need to find a way to take notes along with pictures. I could record some voice memos on my camera if it wasn't inside an underwater housing. Since canoes are very prone to flipping, you don't want to take out an expensive camera while on the water. To safely get pictures on the water I put my camera in an underwater housing that is normally used for scuba diving.

Still on Cherokee Creek. Much of our water travel was not on big lakes but rather streams, small and narrow lakes. The forest here is very dense with brush and small pine trees. The only way to travel any significant distance in this land is by canoe.

Campfire at our first campsite on Cherokee Lake.

My youngest son Daniel (13) slept by himself in a hammock tent. Canoes are stored well within the confines of trees. My brother Cary learned not to store canoes on the lake shore where winds from storms can carry them away.

Day 2: Having breakfast in camp was also an important social time.

Pat grew up exploring the BWCA. Her family started as rookies but honed their skills over decades of practice. They made their own equipment and even their own canoes. Pat's family introduce the BWCA to Cary, who then added his own touch to methods and style. Cary has even done some solo trips into the BWCA.

Making Jiffy Pop popcorn at our second campsite on Cherokee lake. We decided to make day two a short travel day to spend more time playing in camp. This camp we found was a beaut, a rare find in the BWCA. This campsite was the only one on a big island at the northern end of Cherokee Lake.

Day 3: Sunrise on Cherokee lake. I tried to get up early enough each morning to catch the sunrise. This morning the sunrise was glorious. This day we planned to hang around camp or do a day trip and return.

Making bacon for breakfast.

Daniel and I found a nice rock to jump from into the lake. Here we are swimming back from the rock to our campsite.

Cary and Pat did a day trip to Frost Lake and my family stayed more local. After swimming, fishing and catching leaches on our island, the four of us jumped into a canoe and crossed the bay to a beach. Here Chris is doing his favorite thing - fishing.

Daniel and I like to make sandcastles.

Yours truly relaxing in nature's recliner.

Chris watches the sunset at a vista on top of a huge, granite outcropping near our campsite.

Day 4: Renee and I enjoy the sunrise with tea and coffee. Today will be a big day because we'll start on a loop to return to the Sawbill entry point. Our goal is to make it all the way to Brule Lake. At some point we'll be committed to finish the loop. Little did we know that some very difficult portages were ahead.

It's not the rocks you see that are the problem, it's the submerged ones you don't see that can ruin your day. Kevlar canoes are great because they are lightweight, making portages bearable and moving quickly on water. But they don't like contact with rocks. A punctured canoe can result in a really bad day, especially when you are two days away from any help.

Chris and Renee clear the rocks just fine. Chris steered from the stern for the entire trip.

Pat takes a break. Cary and Pat have Duluth packs, which are specifically designed for traveling by canoe and portaging. Duluth packs are shorter and wider than backpacks. Duluth packs and portage packs are optimized for canoes by keeping the weight low to maximize stability. Something you appreciate when the wind is strong and the waves are high.

Daniel took this picture of me carrying a canoe on a rocky portage. This is actually an easy one. During this day we picked our way through a couple of portages with relentless difficult terrain of steep climbs, slippery moss covered rocks, boulders, tree roots and knee deep muck. Care and absolute focus had to be put into every single step. A wrong step could lead to a serious injury.

Renee prepares for another rocky portage.

Cary and I prepare dinner at our campsite on Brule Lake. It felt good to find a vacant campsite after a long hard day of portaging. Cary and I each had a backpacking style camp stove. A canoe is turned upside down to serve as a table for preparing food and washing dishes.

Day 5: Cary and Pat are making pancakes for breakfast and I'm baking a strawberry muffin mix in a backpacking oven.

Checkout the strawberry muffins. Mmmm good. Some of the food wasn't that tasty, but when your hungry enough you'll eat anything. Everything from the backpacking oven was great, that is once I learned how to bake without burning the food to a crisp.

Renee and I washing dishes.

Chris packing his cloths into a waterproof compression bag. By pulling on straps attached to the compression bag, cloths and sleeping bags are squeezed into a much smaller size, resulting in fewer portage packs.

Renee checks our next move on the map.

Lilly pads that covered many of the small lakes were in bloom.

Day 6: Yesterday was a long and hard day with two monster portages, long stretches of water, at late camp setup, and dinner in the dark after waiting out a storm. We were very lucky to find this vacant campsite on Burnt Lake. Here Renee and I are planning out our last day to the Sawbill entry point. The winds are strong and the waves are challenging so careful planning is prudent.

Every campsite in the BWCA has a throne which is placed a little hike away from the campsite.

Cary and Daniel discuss things at breakfast. A lot of bonding happens over the course of a few days with no TVs, cell phones and video games.

Chris on our final portage to Sawbill Lake.

Renee still has a smile after six days of adventure. That's my girl.

Cary carries a 40lb canoe and a 50lb portage pack at the same time. This method eliminates double portaging which can take a lot more time and limits how deep one can travel into the BWCA.

A rest stop at the end of our last portage on Sawbill Lake. The winds are very strong here and some of us are a bit nervous about canoeing on the lake.

We make it back to Sawbill Outfitters with no mishaps. Our adventure is over, but the experience will continue to influence us for a lifetime.