Saturday, April 11, 2015

Back to Ann Arbor

It's a long way to go for a conversation.  But it was a good conversation to have.  Ann Arbor Cancer Hospital called me and asked that I come down and talk to them about my inclusion of a phase one trial of a new medicine for solid tumors.  The week before, they had requested foundation one testing results from my doctor based on my genomic profile. So Thursday I zipped down to meet with a Dr. Schneider and some of his team.

I like the idea of being part of cutting edge science that is learning how to cure cancer.  I also enjoyed learning about how a drug goes to market.  Dr. Schneider said that this drug was working with my own immune system, "teaching" it to specifically identify cancer genes and attack those cells.  I know from watching "The Emperor of All Maladies" that this is the most promising new horizon for cancer research.  He said I was a good candidate but there were currently no openings and besides, they would not take me off a therapy that was working for one that was experimental.  But people are removed from and added to studies all the time and I should stay in touch and let them know if at any time my current therapy was no longer reducing my tumor.  It is great to have this as a back up!

They left me with a packet explaining in great detail the nature of the study, what could be expected, and everyone's rights and responsibilities.  I learned that this drug was tested with monkeys so this group would be the first human trials.  They saw promising results with the monkey tests and it also helped them with estimating dosing and predicting side effects; primarily raised blood pressure and bleeding in the digestive system in patients with bowel tumors.

It's all a bit anticlimactic and ideally I would not need to resort to a trial for some time.  My next CT scan will be on May 1 and so I will know more a few days after that.

Wednesday, April 1, 2015

C Stories

This week is a "rest" week after my first cycle (3 weeks of once-a-week infusion) of Paclitaxel.  Early signs are very good.  First, I have zero side effects that I am aware of.  No nausea, no appetite loss, and no hair loss (though I'm told that will come).  And second, the pain jabs in my liver and my gut pain in general have mostly ceased.  I still have gut pain following eating but that has been consistent for a long time.  If the body truly knows, cancer is being killed.  I met with Dr. Krajewski yesterday and we decided to do another 3-week cycle with just Paclitaxel.  We can always add Ramucirumab down the line or try it by itself after Paclitaxel fails.  I'll get another scan in 4 weeks to see if it is working like I think it is.

Two disclaimers:
  1. I started using Turkey Tail supplements at the same time that I started this chemotherapy regimen.  My brother, Rob, sent me these dried mushroom capsules that are known to boost the immune system in conjunction with chemotherapy for breast cancer.  I should have waited a month or two so I would have a quasi-scientific comparison.  But these might be a factor in my positive results.
  2. I had a blood transfusion.  Sometime after my first cycle, my hemoglobin levels took a dive again.  They decided to give me 2 units of blood this time.  It was a weird experience.  I felt like a vampire.  Particularly in that I felt great afterwards.  I had no idea that I had been dragging so badly.  My latest blood tests show normal levels in all the blood elements.


A news story that caught my eye was a followup on "Cassandra", the teenager from Connecticut who was forced, against her will, by the state to undergo chemotherapy for her curable lymphoma.  Well apparently she is kind of glad that her cancer is now in remission.  She indicated that the chemo was not so bad.  Maybe the state was right this time.

I've also been watching the new 6-hour, 3-part documentary, The Emperor of all Maladies, on PBS.  It is really quite excellent.  I particularly liked the first 2-hour episode which focused on the history of trying to understand and fight cancer.  It is a film by Barak Goodman based on the book of the same title by Siddhartha Mukherjee and "presented" by Ken Burns in his engaging style of filmmaking and writing.  Six hours is a lot of time to spend on such a dark topic but it is a good way to get up to speed on where we have been and where we are going; what cancer is and what it is not.  I have not yet seen the third episode (premiering tonight) but if you can spend just two hours, watch episode one, Magic Bullets, which will make you feel like a bit of an expert on the basics.  You can watch it on line at that link.

Hair started falling out today.  Should have knocked wood yesterday when I wrote that thing about not losing any hair!

Also, I watched part 3 of "The Emperor of All Maladies" and it was excellent.  Shows where cancer research is going.  The first part of the episode discussed "palliative  care" which is sobering but of great interest to me as that is the type of care I am receiving.  But it went on to talk about the genome research.  All cancer is caused by gene mutation.  About 50% of the cancers are linked to an outside force that causes gene mutation (smoking, viruses, obesity, radiation, chemicals, etc.) and about 50% have an unknown cause.  The first 50% can be affected by behavior changes and prevention.  There are lots of promising developments in gene therapy and teaching the immune system to attack cancer cells.

Tuesday, March 17, 2015

Second Opinion

Mary and I just got back from Ann Arbor for our consult with the University of Michigan Cancer Center. It was a great trip all around and we are feeling particularly positive about our "second opinion" and some new opportunities for future treatment.  And to top that off, I just checked the pond in my yard and discovered that at least one goldfish has successfully wintered over under the ice.  And where there is one, there is bound to be others.

Our consult was Tuesday at 10am and rather than get up super early for a cross-state commute, we accepted an invitation from Mark and Susan Pearlman to come down the night before, have dinner, sleep over, and make it a leisurely 10 minute ride to the hospital after a nice homemade breakfast. Mark is a doctor at the very same Cancer Center and more importantly, he and Susan are the parents of Zack Pearlman, a dear friend of Alice in Los Angeles.  We quickly discovered that the whole Pearlman family loves Alice and were willing to extend that respect to Mary and I.  It made all the difference.  We were super comfortable in their home and with their company.  We ate good food, drank good wine, visited with Zack's Sister Allison and her spouse, Leanne (also friends of Alice) and had great conversation until bedtime.

Mark cancelled his morning meeting so he could make us omelets from the fresh eggs of their backyard chickens before heading off for work.  He advised us to get to our appointment early but to be prepared to wait.  We socialized with Susan and made the decision to come back to the house after my appointment to pack up. Well, we did not get there early but rather right on time. And no sooner than I finished a one-sheet questionnaire, my name was called and they took my vitals and ushered me into an examination room.  

We waited hardly a minute before we were welcomed by Dr. Manali Bhave (hope I got that name spelled right) who is in training with the center's senior esophageal cancer specialist, Dr Susan Urba. She took us through my cancer history, fixing some mistakes in the record and ultimately confirming that the choices that my doctors in Grand Rapids were making were right in line with what they would have recommended. Dr. Bhave possessed the gift of being able to type notes while she looked over her shoulder and talked to me. U of M had consulted on my case before and had a record of my cancer DNA which was compatible with successful trials with the drug, Ramucirumab, Dr. Krajewski was considering. After discussing options, she left and came back with Dr. Urba.

Dr. Urba started out by acknowledging that she had received a note from Dr. Pearlman mentioning our friendship and to give me her best care.  Of course she would do that anyway but it felt good to have the connection made.  She concurred with all the stuff that Dr. Mhave told us, recommending that we move forward with the recently approved cancer drug as a companion to the drug Paclitaxel that was started last week and went on to talk about getting me into a "phase 1" trial.  A phase 1 trial can only happen at a University hospital and it involves testing promising new treatments that are not yet approved.  This could happen only depending on open slots and after this current regimen is finished.  The nice thing about it is that it leaves me with more options should this current treatment be ineffective plus the opportunity to be part of scientific discovery for future patients with my cancer.  She thought my overall good health would be a factor in getting me into a study.  She said that someone who had lived three years with this cancer and that much chemotherapy she would normally expect to be brought in in a wheelchair.

We left feeling very good about future options.

We went back to the Pearlman home and had coffee with Susan.  We wanted to take her out for lunch but she was waiting for a delivery and had to pass.  We said our goodbyes and found a terrific Korean restaurant, Tomukun, right next to the Michigan Theater. And then it was back on the road. Two and a half hours and we were home.

Tofu Stew special with all the added "taste" extras
Tomorrow morning (Wednesday) I will see Dr. Krajewski and take on my second dose of Paclitaxel.  The new drug, Ramucirumab, will need to be approved by the insurance company so that will likely start next week.  I'm also hoping to get a new pain drug as Ibuprofen (which works great) is not a good pairing for gastrointestinal complications.  Unfortunately for the first time I am experiencing pain in the liver as one of my symptoms.

And winter seems to be waning so soon I can start getting a bit more exercise and revisit my fish feeding ritual.

Tuesday, March 3, 2015

Turning the page

  It was not unexpected.  I told my doctor 2 months ago that something was happening down in my liver region.  The body knows.

Doctors are pretty easy to read too.  When Dr. Krajewski came into the room he said, “Well let’s start with the labs”, implying that good news would be first.  But he did get around to the results of the scans and they revealed what I had expected.  The regimen of chemotherapy that I have been on for nearly a year was no longer working.  The primary tumor on the liver was nearly double in size since the last scan in November.  And there was some other evidence of “worsening metastases” in that region and around the abdomen.

The thing about chemo when you are employing palliative therapy is that you keep trying new drugs until they no longer work.  Dr. K had a list of the stuff that was known to be effective on my kind of cancer and he had crossed off all the drugs that I had burned through over the 3 years.  There were still a few left and he was recommending an old drug, Paclitaxel, along with a new (approved just last year) companion drug called Ramucirumab.  Because of the newness and some the side effects of the latter, he recommended that I get a second opinion from the University of Michigan Hospital who would have more experience with patients on this drug.

So we are going to start next week with Paclitaxel and if the geniuses at U of M think it is right for me, we’ll add the Ramucirumab in about 3 weeks.

I’ve really liked that previous regimen because the side effects were so tolerable.  There is no telling which of the side effects will come into play with the new drugs but it looks like losing my hair is a common one.  I can live with that.  I just hope it does not affect the taste of food.  I would be sad to lose that again.

As I said, it was not unexpected so I am not at all devastated.  I am grateful that I still look healthy and feel pretty damn good.  I am also in no hurry for the spring or disappointed in cold temperatures.  It is all good and the warm sunny days will come, regardless.

Monday, March 2, 2015

3 years

When I woke up this morning I got to thinking that it was March already.  I knew that it was sometime in March 2012 when I initially got the call from Dr. Lown that the biopsy from my upper endoscopy had come back positive for esophageal cancer.  I just looked back at my calendar and it was March 2 of that year when I received that call.  So as of today it has been 3 years.

Stage 4 esophageal cancer has a reputation for killing people fast.  Hardly anyone with this diagnosis lasts 5 years.  Most don’t last even 1 year.  I am incredibly grateful that I have reached this milestone and still feel very much alive. My body has served me well.

One of my favorite stories (that I probably have already told in this blog somewhere) is how a simple screw-up in an early medical procedure saved or at least extended my life.

When I was first diagnosed as having the adenocarcinoma cells in my esophagus near the junction of my stomach, there was initial concern regarding staging, as early stages are survivable. Unfortunately, most cases are discovered late because by the time you typically experience symptoms, the disease has already spread. Still, there was hope that we had discovered it in an early stage.  A CT/PET scan would tell the story.

After the scan, I received the bad news that there were hot spots in both my liver and in the center of my chest, in the mediastinum area. This could indicate stage 4.  But to be sure that these hot spots were cancer, they would need to be biopsied.  The liver biopsy was done first since it was relative easy to get to… just a poke through soft tissue.  I was told that if that biopsy revealed esophageal cancer cells, that that would indicate metastases and I would be considered stage 4 and they would not bother to biopsy the spot in my chest, as that would require a thoracic surgery and there was no point to put me through that because it would not change my diagnosis.

Well that liver biopsy came back negative for cancer and the thoracic surgery, using the minimally invasive daVinci robot, was scheduled.  The doctor was hopeful that the hot spot in my chest would also be negative for esophageal cancer as that would indicate a lower stage cancer and I would be a candidate for esophagectomy; a major surgery but also the gold standard for surviving this disease.  They would not perform an esophagectomy on a stage 4 patient because it was considered too invasive to put someone through who had perhaps only months to live anyway.

So it was a weird mixed blessing when the results of the thoracic biopsy came back negative for esophageal cancer but positive for a particularly aggressive strain of non-Hodgkins lymphoma.  The good news being that the lymphoma was deadly but curable through chemotherapy and stem cell transplant, and the lack of adenocarcinoma cells meant that my esophageal cancer had not metastasized, meaning I was early stage for that cancer, and was therefore operable.  I had the operation to remove my esophagus days later and a plan was set in place to put me through the chemo to kill any lymphoma left in my body.

But then the other shoe dropped.  The guy who had done the liver biopsy was looking back at reports and decided that he was not 100% sure that the biopsy he had done had actually sampled the concerning spot.  He asked to repeat the liver biopsy.  This was done and this time it came back positive for esophageal cancer.  I was now considered stage 4.

Bad news, right?  But here’s the thing that occurred to me later.  If that first biopsy had not been screwed up and had come back positive, they would not have gone in to test that spot in my chest.  They would never have discovered the fast-growing, deadly lymphoma there and untreated, it would have quickly killed me.  As it turned out, the doctor was able to cut out the entire lymph node with wide margins during that daVinci surgery and evidently he got it all, as it has not returned.  I received the life extending esophagectomy and because of the eventual stage 4 prognosis I was not put through the grueling stem cell transplant rigmarole to cure the lymphoma.  And here I am 3 years later, having a life beyond expectation.

Tomorrow I get the results of last Friday’s quarterly CT scan.  We’ll see if my weird luck continues.

Friday, February 27, 2015

Warm Respite

While Michigan was experiencing bone-chilling cold February temperatures, Mary and I took 9 days to bring some of that cold down to the Sunshine State.  We had a great time visiting my Mom & Dad, who are staying in Clearwater, Florida for a chunk of time, and also Mary’s brother Matt and his wife Karen who live in Bradenton, Florida, about an hour away.  Some of those days were sunny and warm but all days were filled with great company and good food.  And the beach is beautiful even on a chilly day.

We flew in on Allegiant Airlines, a discount airline that charges for amenities like carry-on baggage, choosing your own seat, beverage service, and even using a credit card on their website.  They don’t have a First Class section and one surprise benefit of that is that fellow travelers seemed generally nicer. Flying no frills on the cheap is a common value. No one was pushing to get ahead in the boarding line, there was plenty of space in the overhead compartments and no one seemed grumpy about little inconveniences.  The St. Petersburg/Clearwater airport was small and easy to navigate and we were greeted by the smiling faces of Mom and Dad who were parked right in front of the terminal.

They were renting a doublewide mobile home at a nearby mobile home park where Mary and I had our own bedroom and bathroom.  It was not a particularly beautiful neighborhood... lots of nearby traffic and strip malls... but there were plenty of palm trees and lush gardens that made us feel like we were in Florida.  I was surprised at how quickly it felt like we had jumped right from winter to an illusion of spring.

In the morning, I joined Dad on his routine walk to get a newspaper from the machine in front of a chain restaurant around the corner.  Mom reads them and does the crosswords but Dad does the legwork.

We decided to spend the day at nearby Honeymoon Island StatePark. They have a beautiful beach and a great Nature Center with an awesome hiking trail where you will see dozen’s of Osprey nesting and flying around talking to each other.  There was a bonus Bald Eagle’s nest at the end of the trail where we saw two hatchlings and a parent eagle.  We also ran into a couple of armadillos who seem quite oblivious to having people around them.  I’d never seen an armadillo before so it was a treat to see them up close and try to figure out if they were mammals, reptiles or possibly dinosaurs.

Chip off the old block

Beachside lunch

The old man and the sea


Osprey Hike

What is this creature?

The next day Mom and Dad drove us down to Bradenton where we were greeted by Matt and Karen at their home.  We all dined together for lunch before bidding adieu to the folks.  Matt, Karen, Mary and I hung out in the lush back yard and discussed plans for our next 4 days.  We had splurged on a near-beach, 2-bedroom apartment rental on Anna Maria Island to celebrate Mary and my 8-year Anniversary and Matt and Karen’s “honeymoon” as they had just legally tied the knot the week before; a mere civil rubber stamp to augment their commitment ceremony marriage from years ago.  The “Key Lime Cottage” was large and lovely with a big and well-appointed kitchen, although we had to walk across a busy road to get to the private beach.

There were may highlights to our days on Anna Maria Island, including a wonderful celebratory dinner at Sign of the Mermaid restaurant, Karen’s fantastic cooking, beach wandering, meeting up with Blake, Brie, and Kimber (nephew and nieces), nature hiking, birdwatching, napping and general beneficial laziness.  I’ll let the pictures do the talking.

Happy Anniversary- 8 years!

We will eat you!

Photo standoff

Beach entrance

The balcony of the Key Lime Cottage

Balcony up close

Dinner at the "Sign of the Mermaid"


Lots of room on this beach

Matt & Karen bundled up for sunset view

Yeah, we were there too.

Obligatory selfie

Brie and Blake

Back at Matt & Karen's

Karen whipped up a batch of fresh lemonade. Rum optional.
Matt and Karen delivered us back to Clearwater for the vacation end cap with my folks.  We all had a terrific Vietnamese dinner together before Matt and Karen said goodbye. Mom, Dad, Mary and I watched the Academy Awards together that night. 

The next day was very foggy but we decided it would be a perfect day to try out the very popular Clearwater Beach.  On a nice day you have to get up pretty early to avoid the gridlock traffic of beach-goers.  It was a relaxing day and after lunch we went to the Clearwater Aquarium which is essentially a rehab facility for wounded dolphins, sea turtles and sea otters.  Its claim to fame is being the setting for the Disney movie, "Dolphin’s Tale” and much of their displays had to do with celebrating that movie.  Since none of us had seen it, it was pretty much lost on us but we did see the real life tail-less dolphin “Winter” who stars in the movie.

Mom cooked another amazing dinner and we watched a PBS British baking competition show before heading for bed.

Our last day was a travel day.  Marlee was waiting for us with winter coats at the Gerald R Ford Airport in near-zero temperatures.  The house was welcoming in spite of the cold.  It is always good to be back home.

Saturday, February 7, 2015

Sidetracked to the hospital

I’m home again after an exhausting and unexpected interlude with the hospital.  Still trying to figure out that institution.  You really turn over most aspects of your life to its control.  It has many friendly faces and amenities but there is also a sense of imprisonment. 

WARNING: This post discusses body waste products.  Can you handle that?  If not, skip to lower on the page where you see ***.

It all started with a sense that I have that something is going on in my gut.  I’ve been feeling little twitches in my liver (yep, I know exactly where it resides) and wondering whether cancer is preparing to mess with me again.  I suppose anyone who has ever had cancer suppresses a fear that it could return and the littlest sign of reawakening exposes the hiding place for that fear.  My twitches had me on high alert and therefore I was focused perhaps a little too much on the output of my digestive system.  Is that blood I see or perhaps just the beets I had for dinner two nights ago?  It doesn’t really look like blood and yet it is different from what I’m used to.  I don’t really want to discuss my bowel movements with anyone. I don’t want to talk about this; not with a nurse, not with someone who picks up a phone at a doctor’s office, and not even my wife who has enough to worry about without thinking about my poop too.  I even hope you are not reading this.

Pee, on the other hand, is just slightly easier to talk about.  So when I had two days in a row of urine that was pinkish or maybe orangey, it gave me both concern and courage to call the doctor’s office to see whether that alone was enough to come in early or should I just wait until my regular doctor appointment next Tuesday.  Nurse Jackie checked with Dr. K and asked me to come in to the infusion clinic right away for blood and urine tests.  I got there about 4:00pm on Thursday.

The Lacks Center people are always so wonderful to deal with and there is rarely any kind of hassle and thus it is really a comfort zone for me despite the fact that they typically dump poisonous chemicals directly into my circulatory system.  Since I would need a direct blood draw, when I arrived I asked if Dawn was there today.  She is the best Phlebotomist I have ever encountered.  I have no fear if it is Dawn doing the arm poke.  Dawn was not there. I wondered aloud whether they could do a draw from my port but Nurse Jackie said that they would specifically be doing some clotting tests and the Heparin they use while accessing the port would contaminate the test.  Since my platelet counts have been low and platelets are the clotting agents in blood, the big worry is that there could be internal bleeding. 

So I got the poke from the other Phlebotomist, who on a previous occasion had missed the vein thrice before switching to my other arm.  This time, fortunately, she nailed it right away.  I rendered a orangeish urine sample right afterward (in the bathroom) and then sat around reading the newspaper while the lab tested the samples.

Jackie came back after a bit.  The good news was that there was no blood in the pee sample.  The redness in the urine could mean other things.  The bad news was that the hemoglobin level in my blood sample had taken a dive since the last test.  It was approaching a level where they consider a transfusion.  She asked if I could provide a stool sample.  I gulped a cup of coffee and shortly after, found I was able to oblige.  After more waiting around, the answer came back:  there was indeed blood in the sample.  Jackie said I should report to a hospital room on the fourth floor for intake.  This was not what I had in mind when I made that initial phone call.

*** I slipped into the skimpy hospital uniform and called Mary and then Marlee to let them know they were on their own for dinner and asked brave Mary to bring a few things from the house, including Marlee, so they could pick up my car from the open-air parking lot.  Extra cars can be a hassle when leaving the hospital.

The 4th Floor nurse ran through a huge list of questions, as they must do, and accessed my port for ready access to medicines, saline and blood.  She also sampled my fluids for redundant testing.  Shortly, one of Dr. K’s Physician’s Assistants showed up to help figure out what must come next. She reiterated that the dropping hemoglobin levels were concerning.  The reading from my regular chemo appointment last week had been 11.1.  The reading from the infusion clinic a couple hours ago was 8.6 and the sample that they processed minutes ago was 7.9.  If it hit 7.0, they would give me a transfusion of a couple of units of blood.  She also indicated that they would bring in an upper Gastro-Intestinal Specialist to see if a source for bleeding could be found from the top down.  If nothing could be determined from an endoscopy, then they would likely proceed to a CT Scan.

It was 6:40pm and I was hungry and remembering from before that the kitchen closes at 7:00pm, I requested a menu and ordered enough food to last me until midnight.  The nurse said no food after midnight so I would be properly fasted for a scope in the morning.  She also said I would likely be spending a second night in the hospitl to monitor the blood transfusion.

Then the waiting began.  The food arrived and then Mary and Marlee came up with my iPad and chargers.  The room staff changed. Mary and Marlee left since I was pretty settled and they had not yet eaten. More fluids were taken.  My blood type was tested (O+). I checked out the TV channels but settled on playing with QuizUp, a trivia App on my iPad where you match wits live with other players from all over the world.  I selected the category, “Name the Movie” and played until I was ranked #1 in Michigan, which is about a #238 ranking for that category worldwide.  The nurse popped in to let me know that I would be awoken at 3:00am by a new nurse for more blood tests and so I shut off all electronics and lights and slipped off to sleep easily.

I woke about 2:45am and decided to browse social media until the blood draw.

In the morning at about 7:30am I met a new nurse who reminded me “No food or water”.  She said doctors usually came around sometime in the morning.  She also told me that my particular Type O blood included a rare antibody so they needed to find a couple of pints somewhere that had that same antibodies so my cells would get along nicely with the donor cells.  She said that chemo patients occasionally develop special antibodies.  I wanted to know more about this and she told me she would try to find more info.  But good news… there had been an uptick in my hemoglobin levels. 

Eventually the GI Doc showed up to explain his plans for me.  He thought the blood loss could be coming from an ulcer or a new stomach tumor.  His endoscope could prove or disprove that.  I’ve been through dozens of endoscopies so that was no big deal.  The trouble was, his schedule was already quite full so he could not squeeze me in until sometime in the afternoon.  For me that meant no food or drink for another half day and lots more waiting around.  A different PA colleague of Dr. K came by to say Dr. K would come by after the scoping to let me know what was up.

I downloaded a new book on my iPad and read for a while.  My sister Betsy volunteers at the Lacks Center 3rd floor (on top of an incredibly busy life schedule) so she stopped by around lunchtime for a visit and conversation. My nurse popped in again to say that the hemoglobin levels were continuing to rise and they would be cancelling the transfusion. Also my pee was now a natural pale yellow.  The reddish color had probably been due to dehydration and all these IV fluids they had given me had corrected this.  Finally at about 1:45, a guy from transport showed up to wheel me to my procedure.  By 2:15 they were ready to proceed.

I’ve had better endoscopies, ones where I did not wake up gagging on an instrument in my throat, but the Versed they give you makes you forget most of the experience.  It just begins and then seemingly immediately, you are all done.  Because of the drugs, I am groggy on the rest but I do know that everything looked fine and dandy from his perspective.  I have a picture to prove it.

Back in the room, I ordered some food and waited for Dr. K.  Mary showed up and we waited together.  Finally Dr. K showed up and pretty much told me that I had managed to self-heal and that he was going to release me.  Yahoo!!  We’d continue with our regular chemo schedule and we would do a CT scan after Mary and I returned from our Florida vacation in just a few weeks.  Irrationally, I had more fear about missing this vacation than I did about the possible return of a tumor so this was really good news.

I do kind of feel better now that I am hydrated but that 24 hours in the hospital sure felt like a big, expensive waste of time just to get my pee the right color.  Once you check in, you just kind of have to ride it to the end, wherever that takes you.