From the first moment my wife discovered she had breast cancer, there was a deafening silence from the men I know. Even ones whose wives, mothers or girlfriends had breast cancer seemed to have received a gag order from some Central Cancer Command and did little more than mumble about the experience. Not one to shut up for any known reason, I started this blog…
Not the first person who ever asked this; not the first time we’ve ever asked it – http://breastcancerreaper.blogspot.com/2011/06/why-do-so-many-women-have-breast-cancer.html is there an ANSWER?
Anecdotally, I’ve heard that the reason so many people are dying of cancer is because we simply live longer. The average life expectancy of all Humans on Earth is 67.2 years.
So? That seems like a really short time! How can that be? What did it USED to be? Hmmm…according to Wikipedia (always my initial go-to source), the average lifespan in Greece, Rome, and Inca/Mayan times was 28; in the Caliphates of northern Africa and the Middle East it was 35. That was what, like 2500 years ago? Right.
So it’s pretty much doubled.
I’ve heard that the reason we get cancer now is that even though cancer was PRESENT then, it didn’t have enough time to kill the person it was growing in. People died of old age before symptoms of various cancers like unintentional weight loss, fever, being excessively tired, and changes to the skin appeared. As well, coughing, difficult or painful swallowing, changes in bowel habits, easily felt masses, coughing up blood, or blood in the bowels, the bladder, or the uterus, localized pain or even painless swelling, and possibly a buildup of fluid in the chest or abdomen could be attributed to lots of things in the ancient world, up to and including the Black Death!
While Hippocrates observed tumors of various types (including breast cancer) in ancient times when life expectancy was only 28 years; and the Egyptians were actually removing tumors 2000 years before the birth of Christ, no one had a real handle on cancer until scientists and doctors started to pool their knowledge in the 1700s and 1800s. By then, life expectancy had increased to about 36 years.
“….cancer…[has] always been with us. People have been getting cancer from the earliest days of their existence (whenever that might be). Heck, most animals get cancer. Even some plants get cancer-like growths...the potential for cancer is in each and every living creature…we also know quite convincingly, and all nonsensical prehistoric arguments aside, that the incidence of cancer has increased dramatically over the last century.” (Written by a man who has no credentials except that he likes to write disparagingly…).
“Incidence: In 2000-2004, across Australia, there were 3,083 cancers diagnosed among Aboriginal and Torres Strait Islander people. The most common cancers diagnosed among Indigenous males in this period were of the lung, bronchus and trachea (19% of all male cancer reported), prostate cancer (10%), colorectal cancer (10%), cancer of unknown primary site (6%), and lymphomas (5%). The most common cancers diagnosed among Indigenous females were breast cancer (25% of all female cancer cases reported), cancer of the lung, bronchus and trachea (12%), colorectal cancer (9%), cancer of the cervix (7%) and cancer of unknown primary site (6%). In the same period, more new cases of cancer were reported among Indigenous females (1,598) than Indigenous males (1,485) compared with the non-Indigenous population.” (http://www.healthinfonet.ecu.edu.au/chronic-conditions/cancer/reviews/our-review).
So, what about cancer among non-aboriginal Australians? Go to the site above and scroll down to the chart. If Aboriginal Australians, who eat pretty much the way they always have (this isn’t just “city aboriginals” – this is ALL of them), have cancer – some types being more common among THEM than non-indigenous Australians. Statistics speak more loudly than someone who uses the phrase “nonsensical prehistoric arguments”.
Conclusions? None really except to say that cancer has been with us for a long, long time. There are some cancers that were more common then, some are more common now. “Why are so many people dying of cancer?” So many is a relative term. And the fact is that it’s not important, really. Even mister “nonsensical” and the Australian government will agree that cancers of ALL TYPES needs to be destroyed.
Resources: http://en.wikipedia.org/wiki/History_of_cancer, http://en.wikipedia.org/wiki/Cancer, http://en.wikipedia.org/wiki/Life_expectancy, http://www.jonbarron.org/alternative-cancer/historic-growth-rates-of-cancer
Image: http://www.cancerresearchuk.org/prod_consump/groups/cr_common/@abt/@gen/documents/image/cruk_logo_c.jpg
A NEWLY DIAGNOSED DIABETIC, breast cancer husband's observations mixed up with an alzheimer's son's musings
Saturday, September 29, 2012
Saturday, September 22, 2012
And Onward Against Lymphedema
From the first moment my wife discovered she had breast cancer, there was a deafening silence from the men I know. Even ones whose wives, mothers or girlfriends had breast cancer seemed to have received a gag order from some Central Cancer Command and did little more than mumble about the experience. Not one to shut up for any known reason, I started this blog…
One thing leads to another.
In this case once my wife rammed her hand against the wall last Thanksgiving; once the swelling began – subtle and mostly unnoticed; once she had trigger finger in which the tendon running through a particular finger swelled a bit and no longer slipped and slid through its usually smooth opening; once the doctor gave two shots to the finger with cortisone that certainly cured the trigger finger but made the swelling worse; once the cancer doctor pooh-poohed the possibility lymphedema occurring in one of HIS patients!; once the practitioner who was supposed to order the compression sleeve and glove; once she finally went to a practitioner who did arm massage AND remembered to order the garments…
Now it’s a daily, sometimes painful, always tedious, usually uncomfortable battle to wrap the arm before work, wear the compression glove (AND figure out how to clean it after holding the hands of two dozen grubby kindergartners), and a monstrously over-sized oven mitt looking nighttime compression sleeve (and hoping she doesn’t take it off in the middle of the night without knowing it…)
So, you think it’s tedious reading this?
Try living it.
Just like with the 18 repeats of the every-three-week chemo treatments, healing is not coming fast. In fact, it seems to be not coming at all.
What is it that the massage therapy and oven mitt treatment and daily wrapping is trying to accomplish? The answer to that is simple: push the lymph back into the system when some of the pumps are missing.
As I explained before, lymph carries the white blood cells that fight disease. That’s a good thing, right? Yes. If you get a cut on your finger, the lymph with its white blood cells it pushed through your body not by a heart, but by the bending of your arms, legs and neck. The movement of the muscle squish thumb-sized bags called nodes and lymph squirts out, rushing to the site of the infection.
The squished nodes start to expand again, sucking up spare lymph and sending it on its way.
Of course, these are the very nodes that become infected with breast cancer cells and are cut out.So – if you have fewer nodes, they can’t pump the lymph away and it stays.
And stays.
And stays.
The arm or leg or foot or neck swells with lymph. That is lymphedema.
Sending the lymph back to where it belongs is like trying to replace the ruined water turbines inside of a monstrous hydroelectric dam with hand pumps duct-taped to the outside of the dam. While it can work, the process of pumping them is a daily, sometimes tedious, usually uncomfortable battle before work…
My wife battles lymphedema constantly as well as working at a challenging job with very needy children. I do what I can to support her, but that usually amounts to being a cheer section and sometimes massaging the arm to drain the lymph back down to its home nodes where it belongs.
It’s a long, hard battle and I continue to stand on the sidelines, struggling with what I can and cannot do.
Image: http://www.nationalgeographicstock.com/comp/04/528/1347295.jpg
http://static.flickr.com/79/256223509_4d729312d2.jpg
Saturday, September 15, 2012
BREAST CANCER RESEARCH RIGHT NOW! 2: Targeting How Cells Use Fat To Grow
From the first moment my wife discovered she had breast cancer, there was a deafening silence from the men I know. Even ones whose wives, mothers or girlfriends had breast cancer seemed to have received a gag order from some Central Cancer Command and did little more than mumble about the experience. Not one to shut up for any known reason, I started this blog…
Every month, I’ll be highlighting breast cancer research that is going on RIGHT NOW! Harvested from different websites, journals and podcasts, I’ll translate them into understandable English and share them with you.
Today: http://www.medicalnewstoday.com/releases/249728.php
One of the ways the medical world is exploring cures and treatments for breast cancer is looking at the chromosomes of individuals with different types of breast cancer. Many people undergo tests to determine if the type of cancer they have has a component that they inherited from their family.
Another part of the genetic picture they look at is how the body responds to cancer.
Two cancer researchers (see link above for the technical article) published papers recently that show some disturbing news. In essence, they show that while certain genes will make your cells either really GOOD at burning fat or really BAD at burning fat, if your genes code for good fat burning ability, they might allow the cancer to grow FASTER because they are good at producing energy.
In the September 2012 issues of The Journal of Clinical Investigation and Nature Medicine, researchers write that they have been studying a gene that slows down cancer cell growth for more than 20 years. The PML (promyelocytic leukemia protein) is a tumor suppressor gene that regulates metabolism via the fatty acid oxidation (FAO) pathway – or controls how fast or slow a cell burns up its fat. The faster it burns up fat, the better it grows. The slower it burns up fat, the more fat gets deposited in places you don’t want it – like the belly, thighs and arms.
So you WANT it to be efficient! Yeah!
But if your regular cells burn fat fast, then that means BREAST CANCER cells in particular will do the same thing…therein lies the problem. We know that obesity and Type 2 diabetes are contributing factors to breast cancer, so how can this be treated?
Researchers conclude that “Our next logical step will be to identify a potential path for therapeutic intervention through the opposing Scylla and Charybdis-like threats and benefits of this pathway (referring to the two sea monsters that sailors of mythology had to navigate). Through pharmacological dosage and scheduling, we will come up with a way to reap the benefits of [the fat burning gene] while reducing or even eliminating its risks. The opportunity is there since we have drugs that can [slow down the breast cancer cell’s metabolism without affecting regular cells or speed up regular cell fat metabolism without speeding up cancer cell metabolism], and we have begun testing these concepts right away [using our research animal subjects].”
Image: http://download.cell.com/images/journalimages/1550-4131/S1550413112X00093_covhighres.jpg
Every month, I’ll be highlighting breast cancer research that is going on RIGHT NOW! Harvested from different websites, journals and podcasts, I’ll translate them into understandable English and share them with you.
Today: http://www.medicalnewstoday.com/releases/249728.php
One of the ways the medical world is exploring cures and treatments for breast cancer is looking at the chromosomes of individuals with different types of breast cancer. Many people undergo tests to determine if the type of cancer they have has a component that they inherited from their family.
Another part of the genetic picture they look at is how the body responds to cancer.
Two cancer researchers (see link above for the technical article) published papers recently that show some disturbing news. In essence, they show that while certain genes will make your cells either really GOOD at burning fat or really BAD at burning fat, if your genes code for good fat burning ability, they might allow the cancer to grow FASTER because they are good at producing energy.
In the September 2012 issues of The Journal of Clinical Investigation and Nature Medicine, researchers write that they have been studying a gene that slows down cancer cell growth for more than 20 years. The PML (promyelocytic leukemia protein) is a tumor suppressor gene that regulates metabolism via the fatty acid oxidation (FAO) pathway – or controls how fast or slow a cell burns up its fat. The faster it burns up fat, the better it grows. The slower it burns up fat, the more fat gets deposited in places you don’t want it – like the belly, thighs and arms.
So you WANT it to be efficient! Yeah!
But if your regular cells burn fat fast, then that means BREAST CANCER cells in particular will do the same thing…therein lies the problem. We know that obesity and Type 2 diabetes are contributing factors to breast cancer, so how can this be treated?
Researchers conclude that “Our next logical step will be to identify a potential path for therapeutic intervention through the opposing Scylla and Charybdis-like threats and benefits of this pathway (referring to the two sea monsters that sailors of mythology had to navigate). Through pharmacological dosage and scheduling, we will come up with a way to reap the benefits of [the fat burning gene] while reducing or even eliminating its risks. The opportunity is there since we have drugs that can [slow down the breast cancer cell’s metabolism without affecting regular cells or speed up regular cell fat metabolism without speeding up cancer cell metabolism], and we have begun testing these concepts right away [using our research animal subjects].”
Image: http://download.cell.com/images/journalimages/1550-4131/S1550413112X00093_covhighres.jpg
Saturday, September 8, 2012
I Have To Keep Telling Myself That The “New Normal” Isn’t The “Old Normal”
From the first moment my wife discovered she had breast cancer, there was a deafening silence from the men I know. Even ones whose wives, mothers or girlfriends had breast cancer seemed to have received a gag order from some Central Cancer Command and did little more than mumble about the experience. Not one to shut up for any known reason, I started this blog…
Following Labor Day, school started in Minnesota this week and that means that my wife and I are back into the swing of things again full time. Not that I haven’t been there since the second week of August; not that she hasn’t been training up on new and updated classroom management and methodology…
But this past week was the first week with KIDS!
Two miles of walking a day is pretty much a regular form of exercise for her. But the beginning of the year is ALWAYS harder after a long summer of NOT walking two miles a day!
This fall was no exception – except that it was harder than ever.
Maybe it’s natural aging – even for me, my knees aren’t what they used to be and I have a knuckle or two that feel like they may have a touch of arthritis every once in a while. I can’t stand up without grunting a bit and I have to tell my two-year-old grandson to “slow down! Grandpa can’t keep up with you!” That seems pretty normal for me.
But the first two days of school were murder on my wife! Not joint pains like with me, but muscle aches and pains to a point where she had to take an unnatural number of over-the-counter pain killers. Not that she hasn’t had aches after a day’s hard work. She chases kindergartners from here to eternity and has been doing it for several years. Before that, she did daycare for 17 years. Certainly lots of aches and pains.
HOWEVER…I was talking to another friend of mine, a long-term survivor of breast cancer and she pointed out that while she was pretty sure she was all set to get right back into life and start swinging again, she discovered that while she felt better than she’d remembered feeling in a long time, the FACT was that she was recovering from a recent bout with cancer, surgery and chemotherapy.
The FACT, she discovered, is that a Human body doesn’t bounce back from an ordeal like that quickly. We’re not talking about a bad cold. We’re not talking about walking pneumonia. We’re not even talking about flat-out-on-your-back pneumonia.
We’re talking about a disease so invasive, it can grow to lethal proportions in less than twelve months. We’re talking about surgery as radical as the amputation of a limb. We’re talking about being injected with chemicals so dangerous the handlers must wear goggles, gloves, masks, booties, and dressing gowns lest any get on their skin and cause profound BLISTERING!
No one in their right mind would expect such a victim to recover from such treatment in less than a year. Yet your average breast cancer survivor EXPECTS THAT OF THEMSELVES! They fully expect to go back to a full training regimen training for the Olympics or the Tour de France; they expect to return to caring for children and home without missing a beat; they expect to take up the reigns at whatever career they had to slow down for, snap them and get back up to full speed yesterday!
So – to those of you supporting a wife, girlfriend, mother, grandmother or partner through breast cancer – stand tight beside them, ready to offer an elbow lift if they stumble or slow down and to continue to work beside them toward as complete a recovery as EACH PERSON is capable of. It’s hardly easy, but has proven to be another, newer role I’m growing into.
Image: http://www.wheatlandsalem.org/mediafiles/announcement-the-new-normal-project.jpg
Following Labor Day, school started in Minnesota this week and that means that my wife and I are back into the swing of things again full time. Not that I haven’t been there since the second week of August; not that she hasn’t been training up on new and updated classroom management and methodology…
But this past week was the first week with KIDS!
Two miles of walking a day is pretty much a regular form of exercise for her. But the beginning of the year is ALWAYS harder after a long summer of NOT walking two miles a day!
This fall was no exception – except that it was harder than ever.
Maybe it’s natural aging – even for me, my knees aren’t what they used to be and I have a knuckle or two that feel like they may have a touch of arthritis every once in a while. I can’t stand up without grunting a bit and I have to tell my two-year-old grandson to “slow down! Grandpa can’t keep up with you!” That seems pretty normal for me.
But the first two days of school were murder on my wife! Not joint pains like with me, but muscle aches and pains to a point where she had to take an unnatural number of over-the-counter pain killers. Not that she hasn’t had aches after a day’s hard work. She chases kindergartners from here to eternity and has been doing it for several years. Before that, she did daycare for 17 years. Certainly lots of aches and pains.
HOWEVER…I was talking to another friend of mine, a long-term survivor of breast cancer and she pointed out that while she was pretty sure she was all set to get right back into life and start swinging again, she discovered that while she felt better than she’d remembered feeling in a long time, the FACT was that she was recovering from a recent bout with cancer, surgery and chemotherapy.
The FACT, she discovered, is that a Human body doesn’t bounce back from an ordeal like that quickly. We’re not talking about a bad cold. We’re not talking about walking pneumonia. We’re not even talking about flat-out-on-your-back pneumonia.
We’re talking about a disease so invasive, it can grow to lethal proportions in less than twelve months. We’re talking about surgery as radical as the amputation of a limb. We’re talking about being injected with chemicals so dangerous the handlers must wear goggles, gloves, masks, booties, and dressing gowns lest any get on their skin and cause profound BLISTERING!
No one in their right mind would expect such a victim to recover from such treatment in less than a year. Yet your average breast cancer survivor EXPECTS THAT OF THEMSELVES! They fully expect to go back to a full training regimen training for the Olympics or the Tour de France; they expect to return to caring for children and home without missing a beat; they expect to take up the reigns at whatever career they had to slow down for, snap them and get back up to full speed yesterday!
So – to those of you supporting a wife, girlfriend, mother, grandmother or partner through breast cancer – stand tight beside them, ready to offer an elbow lift if they stumble or slow down and to continue to work beside them toward as complete a recovery as EACH PERSON is capable of. It’s hardly easy, but has proven to be another, newer role I’m growing into.
Image: http://www.wheatlandsalem.org/mediafiles/announcement-the-new-normal-project.jpg
Saturday, September 1, 2012
A Friend Scare, The Minnesota State Fair, The One Year Visit and People Not As On-Top-Of-Things As They Might Be…
From the first moment my wife discovered she had breast cancer, there was a deafening silence from the men I know. Even ones whose wives, mothers or girlfriends had breast cancer seemed to have received a gag order from some Central Cancer Command and did little more than mumble about the experience. Not one to shut up for any known reason, I started this blog…
A good friend of mine, a colleague at work, had a scare four days ago. In for a regular checkup and knowing she’s been cancer free for a bit over two years, she posted on FB that she was going back in for some more tests and a biopsy. The post read, “hoping for the word ‘benign’ tomorrow (had my mammogram today)...and biopsies are not pleasant (my 4th). I knew what was about to happen, when they brought me to the ‘fun room’ after taking 2 additional pics”
Praise God, she DID hear the words benign the next day. I hugged her so hard, she had to say, “Watch out for the boob!”
Apologizing profusely, I replied, “I just couldn’t help it! Sorry! I’m so...so...thrilled for you!”
What I meant, paradoxically, was, “I am so relieved for ME.”
Once again, this brought back to mind the fact that there is such a thing as aggressive cancer. That successful treatments do NOT always beat the monster to death, and we STILL need a cure. That’s what I’ll be riding for next year. That’s what I pray for every time I lift my eyes and heart up to the Lord.
The next event that day was OUR visit to the oncologist. I went with, but didn’t go in with my wife. Not for any more profound reason than that I didn’t want to get in the way. She came out after an hour or so smiling peacefully. “The doctor said there’s virtually no scar tissue. He asked me if I remembered the chemo.” My wife’s smile turned from peaceful to ironic with a few muscle movements as she said, “Oh, yes. I do. Every moment of it.” How can the Human face be so expressive, going from peace to irony with tiny twitches of electrical impulse? I don’t know, but it happens. She added a moment later, “He said he’d have been surprised if anything came back. The treatment was one of the most aggressive he’s ever done.”
*sigh*
We can be a peace for a bit more, now. Yet I’ll never forget the terror of last year; nor the spectre of possibilities in the future. I’ll deal. I can’t get used to it, but I’ll deal. “Faith. Hope. Love. These three; but the greatest of these is love.” (I Corinthians 13:13) That one I can do best after 25 years of marriage – that one has not dimmed, rather it’s grown stronger. That I can do...
I was at the Minnesota State Fair right after the appointment. In the Health Building, I wandered past the Caringbridge stand and stopped to tell them how grateful I am for their ministry/work/whatever. They asked if I wanted to have my picture taken and (of course!) I said, “Sure.” They said that if I tag it and get other people to tag me, a company that makes cards will donate a dollar for each tag, up to $2000! So, if you follow this link, you can tag me (I think…I don’t entirely get this FB tagging thing…) https://www.facebook.com/#!/photo.php?fbid=10152099135520241&set=a.10152094718910241.903860.86180025240&type=1&theater
As to people not doing exactly what they’re supposed to do? My wife was supposed to have a compression sleeve, had gotten the measurements taken and was assured the sleeve and hand would arrive soon by the Nurse Practitioner. Three weeks later, she had tried calling person; tried emailing the person – and was told the NP had no recollection of have done the measurements and couldn’t remember my wife. Grrrr….and what was she supposed to do about THAT? Lymphedema is serious business! How could someone “oops, I forgot” and then lie about it? I’m reasonably certain my wife wouldn’t LIE about someone measuring her arm!
A second NP did the work as well as noting that she had some lymphedema around the upper abdomen as well and gave my wife a compression bra as well! OK – now things are moving.
The lesson here?
YOU ARE YOUR OWN BEST ADVOCATE! Stay on top of everything and question everything – you don’t have to be mean about it, but this is serious stuff here! You can ask questions politely, just like your parents (and kindergarten teacher and middle school teacher and high school teacher…) taught you to do. But ASK!
Image: http://images.agoramedia.com/joybauer/cms/high-cholesterol-improve-heart-health-gallery-woman-talking-to-doctor-320.jpg
A good friend of mine, a colleague at work, had a scare four days ago. In for a regular checkup and knowing she’s been cancer free for a bit over two years, she posted on FB that she was going back in for some more tests and a biopsy. The post read, “hoping for the word ‘benign’ tomorrow (had my mammogram today)...and biopsies are not pleasant (my 4th). I knew what was about to happen, when they brought me to the ‘fun room’ after taking 2 additional pics”
Praise God, she DID hear the words benign the next day. I hugged her so hard, she had to say, “Watch out for the boob!”
Apologizing profusely, I replied, “I just couldn’t help it! Sorry! I’m so...so...thrilled for you!”
What I meant, paradoxically, was, “I am so relieved for ME.”
Once again, this brought back to mind the fact that there is such a thing as aggressive cancer. That successful treatments do NOT always beat the monster to death, and we STILL need a cure. That’s what I’ll be riding for next year. That’s what I pray for every time I lift my eyes and heart up to the Lord.
The next event that day was OUR visit to the oncologist. I went with, but didn’t go in with my wife. Not for any more profound reason than that I didn’t want to get in the way. She came out after an hour or so smiling peacefully. “The doctor said there’s virtually no scar tissue. He asked me if I remembered the chemo.” My wife’s smile turned from peaceful to ironic with a few muscle movements as she said, “Oh, yes. I do. Every moment of it.” How can the Human face be so expressive, going from peace to irony with tiny twitches of electrical impulse? I don’t know, but it happens. She added a moment later, “He said he’d have been surprised if anything came back. The treatment was one of the most aggressive he’s ever done.”
*sigh*
We can be a peace for a bit more, now. Yet I’ll never forget the terror of last year; nor the spectre of possibilities in the future. I’ll deal. I can’t get used to it, but I’ll deal. “Faith. Hope. Love. These three; but the greatest of these is love.” (I Corinthians 13:13) That one I can do best after 25 years of marriage – that one has not dimmed, rather it’s grown stronger. That I can do...
I was at the Minnesota State Fair right after the appointment. In the Health Building, I wandered past the Caringbridge stand and stopped to tell them how grateful I am for their ministry/work/whatever. They asked if I wanted to have my picture taken and (of course!) I said, “Sure.” They said that if I tag it and get other people to tag me, a company that makes cards will donate a dollar for each tag, up to $2000! So, if you follow this link, you can tag me (I think…I don’t entirely get this FB tagging thing…) https://www.facebook.com/#!/photo.php?fbid=10152099135520241&set=a.10152094718910241.903860.86180025240&type=1&theater
As to people not doing exactly what they’re supposed to do? My wife was supposed to have a compression sleeve, had gotten the measurements taken and was assured the sleeve and hand would arrive soon by the Nurse Practitioner. Three weeks later, she had tried calling person; tried emailing the person – and was told the NP had no recollection of have done the measurements and couldn’t remember my wife. Grrrr….and what was she supposed to do about THAT? Lymphedema is serious business! How could someone “oops, I forgot” and then lie about it? I’m reasonably certain my wife wouldn’t LIE about someone measuring her arm!
A second NP did the work as well as noting that she had some lymphedema around the upper abdomen as well and gave my wife a compression bra as well! OK – now things are moving.
The lesson here?
YOU ARE YOUR OWN BEST ADVOCATE! Stay on top of everything and question everything – you don’t have to be mean about it, but this is serious stuff here! You can ask questions politely, just like your parents (and kindergarten teacher and middle school teacher and high school teacher…) taught you to do. But ASK!
Image: http://images.agoramedia.com/joybauer/cms/high-cholesterol-improve-heart-health-gallery-woman-talking-to-doctor-320.jpg
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