Patient Stories

A Very Happy Re-Birth Day for Bone Marrow Transplant Patients & Families

The Bone Marrow and Stem Cell Transplant Center of Winship Cancer Institute performed its first transplant in 1979. On Wed., Sept. 25, 2013, it performed its 4000th transplant.

What did that number mean to lymphoma patient Vicky Scott, who was one of three people receiving a transplant on Wednesday?

“It means that four thousand people get to be with their families, and get a new chance at life,” she said from her room in the special transplant unit.

Vicky, a retired nurse from Enterprise, Alabama, was waiting patiently with her husband Richard for unrelated donor bone marrow cells to arrive for her transplant. Although the infusion is a routine procedure, it is a special moment when the transplanted cells start coursing through the bloodstream and head for the bone marrow to re-start the body’s production of white blood cells.

“We have been able to really decrease risk and side effects with our supportive care and better medications,” said Dr. Jonathan Kaufman, who was on service that day in the unit. “By doing that we can open up transplant to a lot more patients.”

Duane Fulk and his wife Sue, in the room next to Vicky, didn’t have to wait long for his autologous transplant, meaning one with his own stem cells.

“I see this as the final treatment, eradication of the mantel cells, and us going forward without looking back over our shoulders,” said Sue, watching the transplant team perform her husband’s procedure. For members of the team, the 4000th transplant represents the fruition of decades of their experience and dedication to caring for patients.

Like many patients, Duane had a sudden onset of illness that signaled something was wrong. It’s been a year since he was diagnosed with mantle cell lymphoma.

But Vicky has been struggling with auto-immune diseases for years, and in fact received an autologous stem cell transplant ten years ago in Colorado. She has some perspective on how dramatically the procedures and drugs have changed in ten years.

“It’s night and day,” she said. “I was so sick that first time, I didn’t think I was going to make it. This time, I’ve had virtually no side effects from the drugs and other than feeling weak from the disease, I’m in much better shape.”

As Duane neared the end of his transplant, a group of nurses came to his room to sing their own very special version of “Happy Birthday,” a ritual they’ve developed to mark what is for many, a re-birth day.

The lyrics of their song convey the excitement and possibilities of the transplant: “Happy, happy birthday, it’s time to start brand new!”

“The ability to get a transplant represents hope for survival, hope for getting back to life,” said Dr. Jonathan Kaufman.

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From Hospice Care to Healthy with Bone Marrow Transplant

John Seay was diagnosed with chronic lymphocytic leukemia (CLL) in 2010 and was successfully treated with chemotherapy at a center near his home in Cornelia, Georgia. But the chemo resulted in a second malignancy that brought him so close to death, doctors sent him home under hospice care.

Fortunately, John heeded a recommendation to seek out Winship’s Dr. Edmund Waller, who saw John as a good candidate for a matched unrelated donor transplant. Learn more about how bone marrow transplant saved John’s life in the video below:

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Why We Run: A New Type of Togetherness

Bari Ellen & Charles RossBari Ellen and Charles Roberts always had a strong marriage. Togetherness was a major goal for the couple, who married in late midlife. Their shared experience of running a restaurant together, traveling together and moving across country to Arizona for a new life adventure strengthened their bond.

Their togetherness took a wayward turn in 2009, however, when the husband and wife were each diagnosed with cancer within two days of one another. Charles had been sick for months, but doctors couldn’t determine what was wrong. Bari Ellen, who was feeling great physically, had gone to yet another doctor’s appointment with her husband. Charles suggested to the doctor that perhaps he just had an infection, as his wife seemed to have an infection, too.

“She’s got a lump on her neck. Maybe we both just have an infection,” Charles said.

The doctor took one look at the lump on Bari Ellen’s neck and said, “Make an appointment with the receptionist tomorrow.” It was a good thing that she did.

“They did a biopsy, and the doctor told me I had head and neck cancer and that it was pretty far gone. He said he didn’t know what he could do for me,” Bari Ellen remembered.

Her cancer was staged at 4B and the prognosis was poor. Two days after Bari Ellen received her bad news, lab results for Charlie came back announcing that he had acute lymphoblastic leukemia, or ALL.

“We were in a swirl,” Bari Ellen said. “It just came out of nowhere.”

Within a week, Bari Ellen went to Atlanta at the suggestion of her daughter, who works at Emory, to get a second opinion. Her daughter had told her that maybe the couple could find hope and better news at Winship Cancer Institute of Emory University.

“Once we got to Winship and saw their compassion and dedication and their sense of purpose, we got a sense of purpose and hope, too,” Bari Ellen said. “They gave us an action plan; they didn’t just write me off. We knew we had a fight before us, but we knew we could win it.”

Today, as survivors for four years, the Rosses are retired, enjoying grandchildren, exercising, volunteering and taking care to eat healthfully. They are also running races and this year, both of them are registered for the Winship Win the Fight 5K on October 5th. The couple have formed a team called the Ross Re-Missionaries, and are recruiting as many friends and family members as they can.

“After everything we’ve been through, and after everything they’ve done, I said ‘We’re going to start giving back,’” Bari Ellen said.

The randomness of their diagnoses helps the Rosses to understand the importance of cancer research, which is another reason they strongly support the Winship Win the Fight 5K. All money goes to cancer research at Winship and donors can choose a specific cancer type to which they would like to contribute.

“Our doctors were so phenomenal and did so much for us that we want to do whatever we can,” Bari Ellen said. “They saved our lives.”

The Winship Win the Fight 5K is fast upon us! If you want to run or simply help support other runners like the Roberts, visit the Winship 5K website for more information.

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Support Changes & Saves Lives for Bone Marrow Transplant Patients

William Fuentes, a father of two pre-schoolers and a manager at a McDonald’s, had a very busy life in Calhoun, Georgia, one of Atlanta’s northern suburbs. While his wife took care of the little ones, he still tried to help out around the house while managing the duties of a busy restaurant.

William’s busy life only got more complicated when the 30-year-old was diagnosed in 2012 with multiple myeloma, a disease he had never even heard of. The intense back pain he felt turned out to be a result of the disease. He was rushed to the hospital in an ambulance, and then he had to have surgery to repair some of the damage in his back.

And then treatment started. He needed a bone marrow transplant, often a complicated procedure best handled by a team that has a breadth and depth of experience to handle complications that may arise. He turned to the Emory Bone Marrow & Stem Cell Transplant Center of the Winship Cancer Institute of Emory University.

William Fuentes Multiple Myeloma Bone Marrow Transplant Patient

William Fuentes with his family.

William recalls being so afraid and yet wanting to be strong for his children. After they would go to sleep at night, sometimes he cried, he said.

“I just felt so all alone,” William recalls.

But he found the support he received from Winship and the Bone Marrow & Stem Cell Transplant Center not only saved his life, but changed his life. Enrollment in a clinical trial gave him access to a drug that worked on his type of myeloma, something he may not have received had he been treated elsewhere. Equally important to him was the compassionate care he received from his physician, Dr. Ajay Nooka, and the bone marrow transplant team.

“He is the nicest man I’ve ever met,” William said. “I couldn’t have asked for better treatment,” he says. Winship social workers made sure gas cards were available when funds ran low. A team of employees from the clinical trials unit came together and provided Christmas gifts for the Fuentes family.

“My wife is so thankful. We love it here,” says William.

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Bart Dunn – Celebrating 20 Years as a Leukemia Survivor!

There is a very special moment when a bone marrow transplant patient starts receiving the transplanted cells. Stem cells course through the IV line into the patient’s bloodstream, heading for the bone marrow where they will literally re-start the body’s production of blood, the stuff of life.

So it’s fitting that when that moment arrives, the staff of the hospital’s bone marrow transplant unit crowd into the patient’s room with balloons and sing happy birthday. It is truly a re-birth of life.

Bart Dunn Leukemia Bone Marrow Transplant Patient

Twenty years ago, Bart Dunn had a bone marrow transplant at the Emory Bone Marrow & Stem Cell Transplant Center with donor cells from his identical twin brother Steven. He was only 35 at the time, working in his family’s century-old manufacturing business in North Carolina.

Diagnosed with Acute Lymphocytic Leukemia (ALL) at a hospital near his home, Bart was told the best bone marrow transplant (BMT) experts were at the Emory Winship Cancer Institute. He came here needing immediate chemotherapy and radiation treatments to bring his white blood cell count down. It was a long haul before he was well enough to have the transplant. His long-time companion, Patrick, and family members stayed by his side through that very difficult period. For ten days, Bart ran fevers of 105 and says God performed a miracle in bringing him back from the brink.

Bart marked that life-changing moment by giving Winship a plaque commemorating his transplant and recovery. He is now working on a book that recounts his experience.

After Bart’s bone marrow transplant and treatments came to an end, Patrick’s sister, Angie, made a beautiful quilt with figures from the Noah’s Ark story to signify Bart’s new life and new beginning. Bart’s official 20-year anniversary was Feb. 9 this year. He returned to Emory Bone Marrow & Stem Cell Transplant Center in April for a check-up with Dr. Tom Heffner, and was greeted with a surprise party. Robin LaRocco, nurse coordinator in the bone marrow transplant department, orchestrated the event and members of the BMT team joined the celebration, including several who were here when Bart had his transplant. He invited Winship staffers to sign the quilt that symbolizes his cancer journey.

“It was a very long and difficult journey, but I’m so thankful that I made it through,” said Mr. Dunn.

And for the Emory BMT staff (pictured with Bart below) who specialize in providing the kind of individual care needed during the transplant process, nothing is more gratifying than seeing a former patient doing so well twenty years later.

Bone marrow transplant leukemia

Bart Dunn pictured with the Emory Bone Marrow Transplant Team.

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Anticipatory Grief: Mourning for Your Loved One with a Terminal Diagnosis

Anna’s husband was recently diagnosed with terminal cancer. The doctors have arranged for him to start palliative chemotherapy and expect that he will live another year. Anna is grateful for the time she has left with her husband but often finds herself thinking about a life without her beloved spouse. She feels guilty for thinking about his funeral while he is still alive, but she can’t help wondering what it will be like. Will she cry or will she be relieved he is no longer in pain? Anna questions how she can plan for the future while she is in a constant state of emergency…

The cancer journey can be an emotional rollercoaster for everyone involved. Patients and caregivers, like Anna, are forced to deal with a variety of emotions beginning with the diagnosis, continuing through treatment and finally to remission or death. If death is in the foreseeable future, loved ones can experience anticipatory grief.

What is anticipatory grief?

Anticipatory Grief Cancer CaregiversAnticipatory grief is a form of mourning that occurs in anticipation of death. Anticipatory grief is often experienced once patients or their loved ones acknowledge the terminal nature of an illness. This form of grief is most frequently experienced by a caregiver but can also affect the dying individual.

It is important to not mistake anticipatory grief as a lack of faith or a negative attitude. Instead, it should be viewed as a natural human reaction. Anticipatory grief allows individuals time to absorb the reality of loss and address unfinished business such as saying “I love you,” or “I forgive you.”

Anticipatory grief affects the emotional, physical and spiritual being, but does not decrease the amount of grief felt after a death. It is important to remember that all individuals and families experience illness, grief and death in their own unique way.

Symptoms of Anticipatory Grief

According to The National Cancer Institute, the following aspects of anticipatory grief have been identified amongst survivors:

  • Depression
  • Heightened concern for the dying person
  • Rehearsal of the death
  • Attempts to adjust to the consequences of the death

Self Care for the Caregiver

It is crucial for caregivers and loved ones to participate in self care while experiencing anticipatory grief. Below are some specific things that you can do to care for yourself:

  • Talk with a professional, such as a social worker or clergy member, about your fears and emotions.
  • Attend the Caregiver Support Group at Winship.
  • Find little ways to care for yourself throughout the day like going for regular walks, getting plenty of rest and journaling.
  • It’s ok to take a break from cancer and from sadness. Give yourself permission to laugh with friends or see a funny movie.
  • Acknowledge that it is normal to experience a range of emotions during this process such as anger, confusion, sorrow and relief.

Winship Cancer Institute of Emory University offers supportive services to caregivers and patients throughout every stage of the cancer journey. Caregivers like Anna do not have to walk this path alone. The Supportive Oncology Team at Winship focuses on improving the quality of life for patients and families affected by cancer. Call 404-778-1900 to schedule an appointment with a member of the Supportive Oncology team.

About Maggie Hughes, LMSW
Maggie Hughes, LMSW, is a medical oncology social worker at Winship Cancer Institute of Emory University. Maggie assists patients at Winship by providing them with supportive counseling and practical resources. She facilitates the Pancreatic Cancer Support Group and the Triple Negative Breast Cancer Support Group at Winship. Maggie works with the genitourinary, gastro intestinal, breast, gynecological and sarcoma cancer populations. She has a passion for working with grieving families and is currently working on her certification in Thanatology through The Association for Death Education and Counseling. Maggie received her Master’s Degree in Social Work and Certificate in Marriage and Family Therapy from The University of Georgia. While a graduate student, Maggie received the Heather Christina Wright Scholarship for Social Workers in Oncology. Maggie has worked in the geriatric hospital setting and in the school system as a social worker.

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Winship Cancer Institute of Emory University offers The Purdom Chapel as a quiet place for reflection, prayer and meditation. The Purdom Chapel is located on the first floor at Winship and is open during regular clinic hours. Chaplains are available seven days a week, 24 hours a day.

Emory’s Bone Marrow Transplant Team Turns Despair into Hope

Debbie Barth suffered from aplastic anemia, a disease in which bone marrow doesn’t make enough new blood cells, and she was getting worse. She had had blood infusion after blood infusion, but they no longer helped her. She was possibly facing death after two years of living with the illness.

Debbie was being treated at an Atlanta hospital where doctors told her they would not give her a bone marrow transplant, which was her only real hope for surviving the chronic condition that was stealing more of her life each day.

Bone Marrow Transplant Patient

Debbie Barth, pictured at far left behind her mother Joanie, with family.

“I was at the end of my rope, and they wouldn’t even take me,” Debbie said, still incredulous that she could be turned away for what could be live-saving care.

Fortunately for Debbie and her family, someone told her about Dr. Edmund K. Waller at the Winship Cancer Institute of Emory University and the Emory Bone Marrow and Stem Cell Transplant Center. She made an appointment to see him, and that’s when everything changed.

Debbie’s mother Joanie went to the appointment with her. Debbie was again skeptical to hear what a doctor had to say, but this time it was good news. “I can’t tell you how I felt when we got into that room with him that first day,” said Joanie Barth.

“Instead of saying there was no hope,” she recalls, with the help of a bone marrow transplant, “Dr. Waller said my daughter had a “50% to 80% chance of survival.”

“And I said, ‘Dr. Waller, can you tell me whether it’s closer to 50 or 80?’ He looked at me and said, ‘Ms. Barth, Debbie is going to make it.’”

“I just started crying and crying because for the first time, we had hope,” Joanie Barth said. “When he spoke the whole room just filled with hope.”

Many patients like Debbie, who had been told she was too high-risk for a transplant, arrive at the Emory Bone Marrow and Stem Cell Transplant Center having exhausted all other options and time. Some have been turned away from other bone marrow treatment centers because their cases are extremely complicated, or because their prognoses are not good. Now, for patients like Debbie, there is hope.

The Emory Bone Marrow and Stem Cell Transplant Center is one of the most experienced in the nation, with a team of dedicated physicians who treat patients and not just the disease. With experience unmatched in the Southeast for treating hematologic cancers, the Winship team is expert in treating the even the most complicated of cases. This fall, Winship physicians will perform their 4,000th bone marrow transplant.

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Survivor Story: Debbie Church’s Battle with Breast Cancer

Debbie Church

Debbie Church is Coordinator of the Cancer Survivors’ Network and Patient Navigator at Saint Joseph’s Hospital and a 5-year breast cancer survivor. Debbie has shared her story through the journey of survivorship below. We’re lucky to have Debbie and Saint Joseph’s Hospital as part of the Emory Healthcare family and we thank her for sharing her story. We hope our readers and community members are as inspired by her story as we are!

“Dick and I fell in love over 32 years ago and have never quite gotten over it! We have had some interesting moments, but we have made it through each challenge. Love always finds a way. Unexpectedly, our lives changed in an instant when I was diagnosed with breast cancer in December of 2008. We knew life would never be the same. Life is like that box of chocolates – you never know what you’re going to get.”

Read more of Debbie’s story on the Saint Joseph’s Hospital blog >>

About Debbie Church, BA
Debbie Church, BA in Psychology and History, Salem College, and a M.Div. from Southeastern Seminary Wake Forest and a Certified Cancer Services Navigator has worked in oncology for over 20 years. She is currently employed at St. Joseph’s Hospital of Atlanta as Coordinator of the Cancer Survivors’ Network and Patient Navigator. She has worked also as Director of Support Services and Chaplain at Northwest Georgia Oncology Centers, Atlanta Medical Center and various hospitals in the Southeast. She has spoken at many cancer events including GASCO Conferences here in Atlanta and other hospice and oncology centers in the southeast. She was a contributing author for Thomas Nelson’s Women’s Study Bible as well as publishing a book in 2010 with her husband, Don’t’ Ever Look Down; Surviving Cancer Together.

Survivorship Care Plan- Are You Prepared? Take-Aways from Web Chat

Cancer Survivorship SupportRecently, I conducted a chat with Winship Cancer Institute of Emory University on the Effects of Chemo and Radiation on Cancer Survivors. In 1978, as a child, I was diagnosed with Ewing’s Sarcoma. I received radiation and chemotherapy at that time that resulted in my development of significant late side effects in my adult life.

The participants asked some great questions. One particular question we did not have time to answer was,

“Did you find a survivorship care plan an effective tool for you or your parents once you moved from active treatment?”

For me, a cancer treatment summary or a survivorship care plan was extremely helpful after my active treatment. Without the knowledge from my parents and their guidance, I would not have been able to properly prepare a care plan.

I recommend that every cancer survivor become well informed and secure a treatment summary and survivorship care plan.  Consider it the first step in accepting responsibility for your personal health and well-being after cancer treatment.

A Cancer Treatment Summary should include the following information at a minimum:

  • Identifiers for you (name, medical record number and birthdate)
  • A description of your cancer diagnosis including pathology and staging information
  • A list of all treatments you have received (surgery, chemotherapy, biological therapy, hormonal therapy, and/or radiation therapy)
  • All dates and doses of treatment you received  (i.e. cumulative doses of anthracyclines)
  • Any significant side effects you experienced during treatment
  • Contact name and phone number of a member of your family or close friend
  • Names and Contact information of all providers involved in your care

A Survivorship Care Plan should include the following information at a minimum:

  • A Treatment Summary
  • A plan for long term follow-up including appointments and testing you will need and when you should have them
  • A list of any long term side effects that you need to be aware of and ways to handle them (including physical issues as well as emotional and social issues you may experience)

For more information on how to prepare your survivorship plan and the benefits of having one, check out the chat transcript.

About Stephanie Zimmerman

Stephanie’s personal experience as a child diagnosed and treated for Ewing’s Sarcoma in the late 1970’s led her to become a nurse serving the physical and psychosocial needs of children and their families along the cancer trajectory. In April 2008, Stephanie’s heart failed because of the chest radiation and Doxorubicin used to cure her Ewing’s Sarcoma three decades prior. Unable to return to clinical practice following a heart transplant, yet unwilling to abandon her passion for the survivor population, Stephanie partnered with Judy Bode of Grand Rapids, MI in the founding of myHeart, yourHands, Inc. [MHYH]

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We Are Winship – Survive and Thrive

Shawn Ware felt a small lump in her breast while in the shower on January 2nd, 2009, and on that day, the journey on the fight against breast cancer began for Shawn, her husband Albert, daughter Demitria, son Jalen, and mother Eva Freeman. As part of her treatment plan, Shawn underwent a lumpectomy and additional treatment with radiation therapy and chemotherapy.

Shawn Ware, breast cancer survivor

Shawn Ware

“You know those side effects that you see in fine print? I had all those and more,” she says, somehow able to laugh about them now. “I didn’t know that your eyelashes act as windshield wipers, and when I lost mine, I had to wear glasses just to keep things from getting in my eyes.”

Shawn triumphed. “I was ready to conquer the world after my last round of radiation,” she says. And three years later, she is considered a survivor and a reason for celebration.

“Cancer, it stinks,” says Shawn, the general manager of Blomeyer Health Fitness Center at Emory. “But you do change. You certainly learn to appreciate the good and not let the little things bother you any more.”

Like millions of other Americans, Shawn is part of a growing trend—more people than ever are surviving cancer. In just six years, the number of cancer survivors has jumped by almost 20 percent, according to the Centers for Disease Control and Prevention and the National Cancer Institute—11.7 million in 2007, up from 9.8 million in 2001, the most recent years available.

The good news comes with some challenges, however. As cancer treatment has become more successful, survivors —and their caregivers and providers—have learned that there is a cost to surviving.

“Long-term survivorship starts on the day treatment ends,” says nurse practitioner Joan Giblin, the director of Winship’s new Survivorship Program. “You’re actively doing something during treatment, but when treatment ends, many patients tell us they feel like they have been set adrift without a clear course. Our survivorship program is trying to bridge that gap and provide survivors with tools for these difficult times.”

Giblin says that some survivors respond by isolating themselves. Still others “jump right back into their old lives or try to adjust to a new life by adapting to any after-effects they may still be experiencing.”

Survivors of all types of cancer can face myriad physical issues. Treatment itself can be so hard on the body that survivors sometimes suffer chronic pain, heart problems, depression, sexual dysfunction, and a mental fogginess dubbed “chemo brain.” They also are at heightened risk for recurrence and secondary cancers.

Physical problems arise within individual cancer groups. For example, head and neck cancer patients often have trouble swallowing and lose their sense of taste. Breast cancer patients must deal with the changes that come as a result of a lumpectomy or mastectomy and reconstruction.

In addition, family and relationship problems may arise as all in a survivor’s relationship network struggle to adjust to cancer and life after cancer.  Emotional challenges abound, from sadness, fear, and anger to serious depression. Fatigue is common.

Winship Cancer Institute is helping survivors deal not only with the late physical effects of cancer but also with the psychological and social issues that are part of surviving.

“We are now defining a ‘new normal’ for these patients,” says Giblin. “There can be long-term after-effects when treated for cancer, and we are finding ways to improve their quality of life while providing guidance on strategies for dealing with these after-effects.”

The Winship Survivorship Program officially started in November, 2011. Already more than 10 Winship survivorship “clinics” are being offered, focusing on survivors of 10 different cancer categories. The program holds workshops on such vital topics as nutrition, preventing lymphedema, how to talk to children about cancer, spirituality and pet therapy. Workshops have been held on sexuality and also on fatigue. In May, Winship announced its collaboration with the YMCA of Metro Atlanta for a special exercise program for cancer survivors. A unique collaboration, Winship at the Y was Giblin’s brainchild. She is at the hub of a very extensive interdisciplinary wheel that involves specialists from a wide range of treatment areas, including nutrition, pain management, and psychiatry to help survivors thrive.

“We have to change how we look at cancer patients,” Giblin says. “Many cancers are not curable in a conventional sense, but the improvement in the quality and quantity of life needs to be our priority. Much as we view diabetes as a chronic condition, we must look at many cancers in the same way.”

Head and neck cancer survivor Barry Elson, 70, had difficulty swallowing after his treatment. Barry, who was first diagnosed in 2003, had an esophageal dilation last year to improve his ability to swallow.

“I think in the press of your day-to-day survivorship, you forget to ask what (the treatment) might do to your long-term quality of life,” Barry says.

Shawn found that exercise has not only helped her gain physical strength but also has helped her mental outlook. Shawn was able to exercise throughout most of her treatment, even as ill as she was. Now, her worst worry is fatigue. But that doesn’t slow her down. In her job as fitness manager at Blomeyer, she conducts “boot camp” training sessions and teaches other classes.

Winship is also helping survivors thrive by providing support services to help survivors cope with employment and insurance issues that arise as a result of their cancer.

“After treatment,” Giblin says, “patients tend to not be able to work as long, and they don’t have the stamina they used to have.” In addition, there can be stigma in the workplace against a cancer survivor, which in times of layoffs, can result in their loss of employment and consequently, loss of benefits.

“It’s the people who can’t afford to lose their jobs who do,” she says.

And even in cases where survivors keep their insurance benefits, they might find a lack of integrated care as they celebrate more birthdays.

Paper records are lost through the years, hospitals and oncology offices change and primary care physicians—who don’t have experience in oncology —aren’t prepared or educated to provide the ongoing care cancer survivors need.

Barry says he fared well—a result, in part, of diligent Winship physicians Amy Chen and Dong Moon Shin, and the nursing staff—including Giblin.

Despite the side effects she faced during treatment, Shawn says she has grown from her cancer experience.

It makes her a stronger survivor, she says, and also more hopeful, optimistic, and motivated.
“It’s almost motivated me to do more,” she says. “It really helps me to live day by day. You make every day everlasting.”

Original Article Source: Winship Magazine

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