Bill

M : IMO, in a narrow group of well-defined responders, Tarceva can work exceptionally well. Most of the clinical literature indicates that improvement will hold for ~ 6 to 9 months. ( Here's an example article in which irreversible EGFR inhibitors are discussed ). http://www.mgh.harvard.edu/news/release ... haber.html My wife fit the responder criteria exceptionally well. While on monotherapy with Tarceva, she went from near death to very near NED over an ~ 8 to 9 month period. Then, all improvement suddenly vanished over the following ~ 3 months. One surprising fact of this reversal is that ~ 90% of her current, active tumors are in the same locations, that is same distribution pattern, as that before starting Tarceva. Tumor sites thought to be dead obviously weren't even though PET scans during peak improvement showed no abnormal activity at these locations. Even a malignant pleural effusion recently reformed which was identical in size and location to the one that she had just prior to starting Tarceva. B

G : There are multiple potential causes for SOB some of which have been mentioned already. One cause that is often overlooked is simple anxiety. One of my wife's worst bouts of SOB, causing her to be rushed to the hospital, turned out to be due to an anxiety attack. CXR came back unchanged and after she was sedated and reassured all signs of respiratory distress disappeared. B

K : Based on the clinical literature that I'm aware of Tarceva taken in combination with chemotherapy hasn't proven to be of value with the exception of a sub-set of patients that have never, ever smoked. They benefited from the combined tx but I honestly don't recall if the benefit was clinically significant. On a personal note, my wife is currently on a Tarceva / Gemzar / Navelbine regimen. Short term scan data indicates that her pulmonary condition is mixed. The size, quantity and distribution of lung tumors appear unchanged after one month of tx, which is good, but her malignant pleural effusion appears to be slowly reforming. Her difficulty deep breathing suggests this, also. Her ALP level is high but almost unchanged from March to April which suggests stability. My gut feeling is that this tx regimen will hold her largely stable, at best, and at the next update her med onc will have to make some sort of tx adjustment or change. Her RBC values are getting hammered, most likely due to the Navelbine, to the point that the med onc has had to reduce both Gemzar and Navelbine dosages. Tarceva left at 150mg. daily. Good luck. B

There is an enormous amount of drug resource material available. Much of it intended for HCPs but most, if not all, should be obtainable by the general public. Here is a good summary of drug resource material. I thought that it was worth posting because, even though clinical pharmacists and other HCPs usually utilize premium databases and clinical journals for much of their research, there are some titles that I recognize and personally use on a regular basis. Besides this list, Medline Plus is a good on-line reference and Nursing 2006 ( or earlier edition ) Drug Handbook ( pub : Springhouse ) is handy as a quick drug reference. A good general drug compendium is AHFS Drug Information. For pharmacology reference Goodman & Gilman. For drug interactions, Hansten's. Drug Information Adverse Reactions Call Number AMA Drug Evaluations RM300.A553 American Hospital Formulary Service RS125.A56 Drug Facts and Comparison RM300.F33 Drug Interactions RM302.S76 Handbook of Nonprescription Drugs RM671.A1H34 Martindale The Extra Pharmacopeia RS141.3 M4 Physicians' Desk Reference (PDR) RS75.P5 Physicians' Desk Reference for Nonprescription Drugs RM671.A1P48 CAS Number Call Number USP Dictionary of USAN and International Drug Names RS55.U54 Merck Index RS51.M4 Martindale The Extra Pharmacopeia RS141.3 M4 U.S. Pharmacocopeia/National Formulary RS141.2 U48 Case Studies Call Number Clin-Alert RM103.C55 Drug Interactions RM302.S76 Food and Drug Administration RM302.S76 Pharmacy Law Digest KF2915.P4K322 Martindale The Extra Pharmacopeia RS141.3 M4 Unlisted Drugs RS1.U552 Cautions/Warnings Call Number AMA Drug Evaluations RM300.A553 American Hospital Formulary Service RS125.A56 Clin-Alert RM103.C55 Drug Facts and Comparison RM300.F33 Martindale The Extra Pharmacopeia RS141.3 M4 Physicians' Desk Reference (PDR) RS75.P5 Physicians' Desk Reference for Nonprescription Drugs RM671.A1P48 Chemical Formula Call Number Drug Topics Red Book HD9666.1 D75 Goodman and Gilman's The Pharmacological Basis of Therapeutics RM300.P513 Martindale The Extra Pharmacopeia RS141.3 M4 Merck Index RS51.M4 USP Dictionary of USAN and International Drug Names RS55.U54 U.S. Pharmacocopeia/National Formulary RS141.2 U48 Chemical Structure Call Number AMA Drug Evaluations RM300.A553 American Hospital Formulary Service RS125.A56 Goodman and Gilman's The Pharmacological Basis of Therapeutics RM300.P513 Martindale The Extra Pharmacopeia RS141.3 M4 Merck Index RS51.M4 Physicians' Desk Reference (PDR) RS75.P5 Physicians' Desk Reference for Nonprescription Drugs RM671.A1P48 USP Dictionary of USAN and International Drug Names RS55.U54 U.S. Pharmacocopeia/National Formulary RS141.2 U48 Dosage/Form Call Number AMA Drug Evaluations RM300.A553 American Drug Index RS355.A48 American Hospital Formulary Service RS125.A56 Drug Facts and Comparison RM300.F33 Handbook of Nonprescription Drugs RM671.A1H34 Physicians' Desk Reference (PDR) RS75.P5 Physicians' Desk Reference for Nonprescription Drugs RM671.A1P48 Remington's Pharmaceutical Sciences RS91.R4 Martindale The Extra Pharmacopeia RS141.3 M4 U.S. Pharmacocopeia/National Formulary RS141.2 U48 Drug Interactions Call Number Drug Facts and Comparison RM300.F33 Drug Interactions RM302.S76 American Drug Index RS355.A48 American Hospital Formulary Service RS125.A56 Drug Facts and Comparison RM300.F33 Evaluations of Drug Interactions RM302.E94 Handbook of Nonprescription Drugs RM671.A1H34 Physicians' Desk Reference (PDR) RS75.P5 Physicians' Desk Reference for Nonprescription Drugs RM671.A1P48 Remington's Pharmaceutical Sciences RS91.R4 Martindale The Extra Pharmacopeia RS141.3 M4 U.S. Pharmacocopeia/National Formulary RS141.2 U48 Equivalent Drugs Call Number AMA Drug Evaluations RM300.A553 American Hospital Formulary Service RS125.A56 Drug Facts and Comparison RM300.F33 Evaluations of Drug Interactions RM302.E94 Goodman and Gilman's The Pharmacological Basis of Therapeutics RM300.P513 Handbook of Nonprescription Drugs RM671.A1H34 Martindale The Extra Pharmacopeia RS141.3 M4 Remington's Pharmaceutical Sciences RS91.R4 USP Dictionary of USAN and International Drug Names RS55.U54 Unlisted Drugs RS1.U552 Generic Name Call Number AMA Drug Evaluations RM300.A553 American Drug Index RS355.A48 American Hospital Formulary Service RS125.A56 Drug Facts and Comparison RM300.F33 Drug Interactions RM302.S76 Drug Topics Red Book HD9666.1 D75 Handbook of Nonprescription Drugs RM671.A1H34 Merck Index RS51.M4 Physicians' Desk Reference (PDR) RS75.P5 Martindale The Extra Pharmacopeia RS141.3 M4 Remington's Pharmaceutical Sciences RS91.R4 U.S. Pharmacocopeia/National Formulary RS141.2 U48 USP Dictionary of USAN and International Drug Names RS55.U54 Unlisted Drugs RS1.U552 Identification Call Number Drug Topics Red Book HD9666.1 D75 Physicians' Desk Reference (PDR) RS75.P5 Physicians' Desk Reference for Nonprescription Drugs RM671.A1P48 Indications/Contra-Indications Call Number AMA Drug Evaluations RM300.A553 American Hospital Formulary Service RS125.A56 Drug Facts and Comparison RM300.F33 Physicians' Desk Reference (PDR) RS75.P5 Physicians' Desk Reference for Nonprescription Drugs RM671.A1P48 Remington's Pharmaceutical Sciences RS91.R4 Martindale The Extra Pharmacopeia RS141.3 M4 Legal Aspects Call Number Food and Drug Administration KF3871.O72 Food and Drug Library ( Computer CD-ROM Database) Ask at RefDesk Pharmacy Law Digest KF2915.P4K322 Maunfacturer (* has separate address list) Call Number *AMA Drug Evaluations RM300.A553 *American Drug Index RS355.A48 Drug Facts and Comparison RM300.F33 *Drug Topics Red Book HD9666.1 D75 Goodman and Gilman's The Pharmacological Basis of Therapeutics RM300.P513 Handbook of Nonprescription Drugs RM671.A1H34 Merck Index RS51.M4 *Physicians' Desk Reference (PDR) RS75.P5 *Physicians' Desk Reference for Nonprescription Drugs RM671.A1P48 Martindale The Extra Pharmacopeia RS141.3 M4 USP Dictionary of USAN and International Drug Names RS55.U54 Metabolism Call Number AMA Drug Evaluations RM300.A553 American Hospital Formulary Service RS125.A56 Drug Facts and Comparison RM300.F33 Drug Interactions RM302.S76 Evaluations of Drug Interactions RM302.E94 Goodman and Gilman's The Pharmacological Basis of Therapeutics RM300.P513 Handbook of Nonprescription Drugs RM671.A1H34 Physicians' Desk Reference (PDR) RS75.P5 Martindale The Extra Pharmacopeia RS141.3 M4 National Drug Code Call Number Drug Topics Red Book HD9666.1 D75 National Drug Code Directory (a listing of drug code numbers) HE20.4012 Pharmacokinetics Call Number AMA Drug Evaluations RM300.A553 American Hospital Formulary Service RS125.A56 Drug Facts and Comparison RM300.F33 Evaluations of Drug Interactions RM302.E94 Goodman and Gilman's The Pharmacological Basis of Therapeutics RM300.P513 Handbook of Nonprescription Drugs RM671.A1H34 Physicians' Desk Reference (PDR) RS75.P5 Martindale The Extra Pharmacopeia RS141.3 M4 Preparation Call Number AMA Drug Evaluations RM300.A553 American Drug Index RS355.A48 American Hospital Formulary Service RS125.A56 Merck Index RS51.M4 Physicians' Desk Reference (PDR) RS75.P5 Price Call Number Drug Topics Red Book HD9666.1 D75 References Listed Call Number AMA Drug Evaluations RM300.A553 Drug Interactions RM302.S76 Evaluations of Drug Interactions RM302.E94 Goodman and Gilman's The Pharmacological Basis of Therapeutics RM300.P513 Handbook of Nonprescription Drugs RM671.A1H34 Merck Index RS51.M4 Martindale The Extra Pharmacopeia RS141.3 M4 Unlisted Drugs RS1.U552 Side Effects Call Number AMA Drug Evaluations RM300.A553 American Hospital Formulary Service RS125.A56 Drug Facts and Comparison RM300.F33 Goodman and Gilman's The Pharmacological Basis of Therapeutics RM300.P513 Physicians' Desk Reference (PDR) RS75.P5 Physicians' Desk Reference for Nonprescription Drugs RM671.A1P48 Remington's Pharmaceutical Sciences RS91.R4 Therapeutic Use Call Number AMA Drug Evaluations RM300.A553 American Drug Index RS355.A48 American Hospital Formulary Service RS125.A56 Drug Facts and Comparison RM300.F33 Evaluations of Drug Interactions RM302.E94 Goodman and Gilman's The Pharmacological Basis of Therapeutics RM300.P513 Handbook of Nonprescription Drugs RM671.A1H34 Merck Index RS51.M4 Physicians' Desk Reference (PDR) RS75.P5 Physicians' Desk Reference for Nonprescription Drugs M671.A1P48 Remington's Pharmaceutical Sciences RS91.R4 Martindale The Extra Pharmacopeia RS141.3 M4 Unlisted Drugs RS1.U552 U.S. Pharmacocopeia/National Formulary RS141.2 U48 USP Dictionary of USAN and International Drug Names RS55.U54 Trade Name Call Number AMA Drug Evaluations RM300.A553 American Drug Index RS355.A48 American Hospital Formulary Service RS125.A56 Drug Facts and Comparison RM300.F33 Goodman and Gilman's The Pharmacological Basis of Therapeutics RM300.P513 Merck Index RS51.M4 Physicians' Desk Reference (PDR) RS75.P5 Physicians' Desk Reference for Nonprescription Drugs RM671.A1P48 Remington's Pharmaceutical Sciences RS91.R4 Martindale The Extra Pharmacopeia RS141.3 M4 Unlisted Drugs RS1.U552 U.S. Pharmacocopeia/National Formulary RS141.2 U48 USP Dictionary of USAN and International Drug Names RS55.U54 /////////////// B

A : As I've recommended in other posts, you have to ask the right pharmacist. When it comes to more complicated clinical questions you should ask to speak with the hospital's clinical pharmacist. He or she is the indepth drug expert. For basic product info, pricing, etc. re: outpatient meds any retail pharmacist is fine. For the same type of inpatient info ask a hospital pharmacist. B

IMO late stage cancer carries it's own stigma and tx decisions can be cold and cruel as it boils down to allocating dollars vs. prognosis. My wife just received authorization for some very expensive heroic tx with an unknown amount of SNF / nursing care to follow. The criteria that she had to meet in order to qualify was as follows : " Extremely serious, urgent or emergent medical condition typically requiring complicated intervention and with a high potential for dire outcome if treatment requested is disallowed ... " Never thought that it would be beneficial for her to be so sick. And, this isn't the first time that this criteria has been required. B

IMO, Alimta has turned out to be a much harsher chemotherapeutic agent than originally promoted. Tarceva is much easier on the RBC levels. My wife rarely needed Procrit while on monotherapy with Tarceva. Now that she is back on combination chemo tx her RBC related #s are much lower and she gets 60,000 units of Procrit every week. The only hematology related issue that I have discovered with Tarceva is that it can cause an unpredictable elevation in some of the liver function levels. B

L : I'll limit my reply to question # 2 as it happens to be a pet peeve of mine. IMO, esp. as an out-patient, there is little to no real coordination b/w any of the mythical medical team members. Not just med onc and rad onc. Based on my experience personally and professionally it's a highly fragmented group of practitioners each acting, for the most part, independently and not really motivated to work as a team. It's usually you, the patient or caregiver, orchestrating any coordinating that occurs. This fragmented tx approach is also potentially dangerous. Duplicated, conflicting tx, etc. B

Nancy : If your pain is moderate to severe you might ask the doc to try an oxycodone regimen. If the pain is moderate maybe a Vicodin ES regimen will suffice. Generally speaking, all of these opiate compounds have some undesirable side effects. But, some of these side effects will subside with time. Good luck. B

Ironically, this technology may have an unintended detrimental impact on cancer patients. Namely, insurance companies, as part of on-going cost-cutting efforts, mandating as a condition of reimbursement that med oncs treat their cancer patients based on chemosensitivity testing results to the exclusion of other tx agents that may very likely have tx value but don't meet the testing criteria. Depending on the specific cancer and patient particulars, some patients may end up with a very short list of agents approved and available for their tx and, possibility, a reduced survival time to match. IMO, the bottom line for cancer patients is if you sift thru the mass of literature on chemosenstivity testing you will find no credible data that such testing will produce a clinically significant improvement in patient survival time. IMO, once this technology is commercially established the biggest beneficiaries will be the insurance companies. JMO B

Lindy " Has anyone any idea about a swollen tummy? Thanks " Lindy : L/T higher dose corticosteroid use can cause abdominal distention. Liver disease / damage can produce abdominal distention ( ascites ). I don't really see anything in your post or bio to indicate these causes but you know the case specifics well enough to know whether either of these causes are possible. If so, inform the doc accordingly. Good luck. B

G : I think that you've essentially answered your own question. Based on my search for medical opinion on utilizing chemosensitivity testing it's been a wholesale rejection of this technology from those questioned. The reasoning is as I have laid out in my previous posts including numerous personal contacts and clinical opinion such as this one : http://www.aetna.com/cpb/data/CPBA0245.html Another limitation is that the typical private practice med onc simply doesn't have that many suitable chemotherapeutic drugs in his or her arsenal to fight a given cancer. Any competent med onc will very likely make an effort to utilize all of these suitable drugs on a given patient and should be able to utilize them in a reasonably intelligent rationing order. Assuming in vitro vs. in vivo reliability ( which, as you state, is a questionable issue ), I can envision this testing being more beneficial when the day comes that a med onc has a very large group of suitable drugs ( including some curative ) available for a given cancer patient. We will just have to wait and see how med oncs deal with cures when that day hopefully comes. B

A : I'd summarize the current status of chemosensitivity testing this way. Assuming that a reliable correlation b/w in vitro ( lab ) test results and in vivo ( patient ) response does exist, chemosensitivity testing, at this stage of knowledge, would better organize chemo tx and tumor response ( shrinkage ). Unfortunately, until a cure is found, a better organized tx regimen with improved tumor shrinkage does not correlate with a clinically significant improvement in survival time. IMO, an experienced med onc with lots of trial and error experience with various combination chemo regimens can most likely administer a tx regimen that is at least comparable in survival time to what you'd get by strictly adhering to chemosensitivty testing results. Possibly a better result could be obtained by the experienced med onc if you consider the possibility that drugs ruled out by chemosensitivity testing may have tx value if administered in the right combination(s). I, for one, prefer that my wife's med onc try any chemo combination, no matter how ineffective it appears on paper, if he is confident, based on experience, that said chemo combination has tx value. Individualized tx theory has merit but it's not etched in stone. B

A : This was one of the criticisms that I heard from some of the med oncs and OCNs that I spoke with re: chemosensitivity testing. Chemotherapeutic agents that were ruled out based on chemosenstivity testing, as well as previously failed in practice, are being reused in different tx combinations with varying degrees of success. Most of this defies what I know about pharmacology, synergism, etc. but oncology is full of unknowns. My wife's current chemo cocktail looks like a loser on paper but she is still alive and now off of oxygen. So, obviously there's been some improvement in her respiratory function since starting this new tx regimen. When I confronted her med onc about this he confidently replied that he expected a favorable response based on trial and error with this and similar combos. Also, this type of therapeutic action unhinges the long-standing theory in oncology that failed chemotherapeutic agents can't be successfully reused. B

Greg >> A patient responds to therapy when their tumor shrinks, but apparently this has nothing to do with survival. A tumor responds, that is, shrinks a little, then quickly grows and spreads. The cancer comes back with a vengeance and the cancer patient is given a death sentence by his/her oncologist who will wash his hands of it. Greg - this stqatement of yours is exactly what we are coming up against. this is also the explanation given why tumor shrinkage doesnt have much to do with survival time. 1 oncologist told us that chemo testing would be very valuable if there was a pool of chemo drugs availsble that contained some drugs that cured cancer not just delayed progression of the cancer. this is the main reason given why they are not excited asbout chemo testing right now. reshuffling the order doesnt help much rob

1 of my mothers pulmonary - critical care doctors reports that my mother has > cut-off markings on her lungs rob

Greg - I will reply cuz the question was put out by me not my father and he is seldom home these days. we understand the testing theory and it sounds very promising. the problem is what usually happens in the lab compared to actual medical practice. the results seen in the lab arent reproduced that effectivwely in actual medical practice on real patients. I wish it werent so cuz my mother would benefit but 1 oncology dr after anotehr says the same thing. chemo sensitivity testing doesnt help much to extend survival time. just reshuffles the chairs. might also be do to the fact that most patients arent diagnosed til later stages. my moms oncologist said that he will send a sample of her next pleural effusion for chemo testing if she requests it but he doesnt expect it to make much difference in her survival time. I spoke with 1 of the main chemo lab experts in southern cal.. he said that except for the navelbine strength < reduced do to the combination of drugs > that the chemo mix that my mother is on right now sounds good to him rob

my father says that chemo sensitivty testing looks like another example of the in vitro vs in vivo disconnect. nobody here is saying that there oncologist uses this chemo sensitivity testing and I would think that it would be used a lot if it worked.. the slew of doctors and nurses that my father has spoken with which has included a couple of out of state cancer research centers all say that survival time is not really improved with chemo sensitivity testing. they say that most chemo drugs available for a certain type of cancer will work for a time no matter what order you give them and use them up. in fact in my mothers case 2 of the 3 drugs being used right now are previouisly used drugs that have failed which my father wasnt happy about but believe it or not they seem to be working in this new combination. at least for now working well enough to keep my mother alive and hold back further lung damage. and she isn;t the only one. this is a new treatment trend along with Tarceva in our area according to what I am told. so much for the theory that failed chemo drugs cant be reused. the good news is that it looiks like failed drugs can be resued if they are reused in new treatment combinations rob

katie- thanks for the suggestion. heres the question - has anybody been treated by a oncologist that uses chemo sensitivity testing method in choosing chemo drugs/ please post the effectiveness of it in your real life case, thanks. NancyB - it sounds like even though you had tumor tested for chemo sensitivity that you dont know if it actually helped with your treatment or not. any idea on that/ I have a second question thats sort of related. I stayed up all nite sifting through my fathers medical data bases. It looks like cancer vaccines arec still in various stages of clinical studies. are there any cancer vaccines ready for commercial use ? thanks Rob

katie -my mother has been to 3 hospitals in the last 2 weeks. thoracic surgeon is talking about some sort of catheter implant for her lung fluids but he doesnt know if my mother can tolerate the surgery. I havent spokern with my father since yesterday morning. a friend that has seen them says that the doctors are all doom and gloom which is nothin new to us. BTW my father cant find any medical oncologist that currently uses chemo sensitivity testing. several people have told us that they are familar with this type of testing and have used it but they say that results arent that differnet compared with using set drug protocols so they are luke warm on the subject now .. has anybody been treated by a oncologist that uses sensitivity testing method in choosing chemo drugs/ please post the effectiveness of it in your real life case, thanks. rob

My wife has enough strength and motivation to try one last chemo cocktail commencing Tuesday. This tx MUST, at a minimum, work quickly and well enough to back her away from the edge of the cliff. Her pulmonology / critical care physicians ( all 3 of them ) said the same thing to both of us. She has so little functional pulmonary tissue left that further tumor progression would put her on a ventilator. That she doesn't want. Unless there's been a last minute change that I'm unaware of, her med onc plans on sticking with the first line of tx that I posted previously ( Arsenal post ). I don't particularly care for the regimen. I wish that he would be more aggressive given the circumstances. But, it wouldn't be the first time that I misjudged tx. Hopefully, I'll be wrong about this tx combo. I checked her RX orders on Friday and those are the drugs that were ordered and have arrived for her. B

Thoracentesis certainly looks like a crude and painful procedure. My wife had 2 liters of malignant fluid drained from her right lung Thursday afternoon. ( BTW, I think that they had to switch to a larger needle than originally planned. I overheard the doc state that the fluid was " thick " and the tech scrambled for some additional equipment. ) I have a question for those of you that have had a large pleural effusion drained. It's understood that there would be some residual pain but, since this procedure, my wife is complaining of rather severe pain in the right shoulder area with movement, deeper breathing, sneezing etc. How was your pain in the days following your thoracentesis ? She had a thoracentesis a year ago but she was heavily medicated in ICU at the time so she doesn't even remember the procedure let alone how painful it was. I reported this to the pulmonologist but he was unconcerned. Thanks. B

I appreciate the understanding on me asking this touchy question. I offered to pay this and must face this and I want to do the right thing but funds are limited. I went through my fathers pile of medical business cards and found a couple of hospital social workers cards. I will ask them for help may be. My father has been financing 3 family health crisis all at this same time.. my mom and another family member is in a nursing home and another one is disable by stroke. even with insurance on my mom his out of pocket portion has been big. he also had to pay for some outside opinions and a couple of medical procedures that werent correctly authorizedc so insurance wouldnt pay and he had to pay. my moms med bills are way over $1 million. I was warned to be careful about arrangements as that industry i am asking about has its share of rip offs. this is why I am asking for guidaence on this touchy subject Robert

I'm Robert - Bill's son. excuse the poor explanation that follows but I dont have any medical background. it looks like my mother has just about reached the end. shes been in the hospital since yesterday morning. cant stop the fluid in the lungs. 2 large bottles of what the Dr called exudate sitting next to her bed whne I left. never heardd her scream so much as when the Dr kept jabbing her back with needles and drains. Dr says that her lungs are marblized with cancer. he mentioned a drain that can be surgically impplanted into the abdomen or something like that but say the surgery may not be worth it. shes on huge dose ofoxycodone and the ######## ! med oncologist only remarks are that he will procede with chemo if she wannts. no urgency in his mind and no plan to change drugs to more aggresive stuff.. to him shes just another patient going out the back door while a new 1 enters the front. at some point my father will give you a better up date but this is such a mess and so upsetting that I dont kno when. the pulmonoligist says that my mothers lungs could arrest at any time. he sees very little fiunctional tissue left and gives her a few days to a few week depending on chemo. my mother wants to be cremated with her ashes spread in the Pacific ocean like with neptune society. can anybody explain the useual process for arranging and doing this and ways to do it to keep costs down.? Thank you very much

Karen : Good, honest answer. I hate to say it, but you are almost better off if you are busted ( with house, car exclusions, modest income and meager assets.) B