Smilow Shares with Primary Care: Survivorship

June 07, 2023

Information

June 6, 2023

Presentations from:

Maryam Lustberg, MD, MPH, Associate Professor of Internal Medicine (Medical Oncology); Director, Center for Breast Cancer; Chief, Breast Medical Oncology
Tara Sanft, MD, Associate Professor of Medicine (Medical Oncology); Chief, Patient Experience Officer; Medical Director, Survivorship Clinic
Brian Williams, MD, Medical Informatics Officer, NEMG

ID10035

To CiteDCA Citation Guide

00:00Fantastic. Let's get started.
00:02I we have the pleasure of having Dr.
00:05Kevin Billingsley, our Milo CMO today to
00:09to start us off and welcome everyone. You
00:14know, I I am thrilled to be here
00:17and I want to thank the audience.
00:20For not just participating in this event,
00:22but for the participation over the
00:25months in this series of Smilow shares,
00:28the partnership and collaboration between
00:31clinical oncologists and primary care
00:34physicians is not only fun and rewarding,
00:37it's the best possible thing for
00:39all of our patients together.
00:42So I have to say I'm incredibly
00:44excited about the topic this evening.
00:49You know the the
00:49statistics in 2022 are that
00:52there are currently over 18
00:54million cancer survivors out
00:56there in the United States today.
00:59You know I think it is,
01:02it's extraordinarily gratifying.
01:03I think it's a testament to the
01:06development and our our abilities
01:09to treat patients and sustain them
01:11through the course of their illness,
01:14but it is also.
01:17A testament to our medical
01:19community in general,
01:20particularly our primary care
01:22physicians who support patients and
01:25families through the continuum of
01:27healthcare throughout their lifetime,
01:29including supporting them through
01:32significant illness like cancer,
01:34heart disease and other other
01:36chronic diseases that they manage
01:38them in partnership with specialists
01:42so. I think we have a
01:45fabulous panel this evening.
01:47I'm just going to say I'm incredibly excited.
01:49I think it's going to be a great discussion.
01:52And I want to also take a minute
01:56to recognize and thank our
01:58fearless Co leaders in this.
02:00In this program.
02:01Doctor Ann Chang who's the Associate
02:04Cancer Center Director here at the
02:06Yale Cancer Center and our Director
02:08of Clinical Initiatives and Dr.
02:10Karen Brown who's the Medical Director
02:11of Primary Care for Northeast.
02:13Medical Group,
02:15thank you both for really leading
02:18this effort and driving this level
02:21of communication and engagement
02:23between the primary care docs
02:25and our our oncologist.
02:27So terrific and I know you guys
02:29will introduce our panelists.
02:31So over to you Ann and Karen.
02:34Thank you Kevin,
02:38we. This is our last program for the
02:43year that Karen and I am working on
02:46and this really came out of discussions
02:48that we had where we felt that there
02:51could be a better relationship and
02:53better communication about cancer.
02:55And updates, but really from
02:57the primary care perspective.
03:00So I see some of you have been
03:02regulars and we really appreciate
03:05you coming and appreciate your
03:08feedback on this since we, you know,
03:10we're we're talking about what
03:17And I your audio just got quiet.
03:22OK Can you hear me OK?
03:24Yeah, OK. Sorry about that.
03:27So we're going to have three
03:30cases tonight and then we will
03:32have time about 10 or 15 minutes
03:34hopefully for for questions.
03:36And I know that you all have really
03:38great questions and I think that
03:40the presentation of the cases
03:41tonight will really prompt that
03:43we'll have questions for Dr.
03:44stamped around survivorship
03:47after the first case.
03:50And then the rest of the question.
03:51So please have a few questions
03:53ready and then we'll have time for
03:55the rest of the questions later.
03:57And then without further ado,
03:59I will introduced Dr.
04:01Tara Sam,
04:02who's an Associate Professor
04:04of Medicine and she's our Chief
04:07Patient Experience Officer and
04:09Smilo and the Medical Director
04:12of the Survivorship Clinic.
04:13She is doctor Stamp earned
04:15her medical degree from the
04:17Medical College of Wisconsin.
04:20She completed her residency
04:21and fellowship at Northwestern.
04:23She is board certified in both medical
04:26oncology and Hospice and palliative medicine,
04:29which she feels helps to her to treat the
04:32whole person and not just the disease.
04:35And as a breast oncologist,
04:36she is a very busy practice and
04:39enjoys taking care of women with
04:42newly diagnosed breast cancer and
04:44in her role as the chief patient.
04:46Experienced officer She focuses
04:48on how to improve care,
04:52especially where the provider
04:54and patient experience overlap.
04:57She is the director of our
04:59Smiler Survivorship Clinic,
05:00one of the nation's only
05:02multidisciplinary clinics,
05:03especially in specializing
05:05in cancer survivorship.
05:07And she learns from patients
05:09about key issues after treatment,
05:11which also informs her role as chair
05:13of the National Comprehensive Cancer.
05:16Network survivorship guidelines
05:17and finally her research interests
05:20focus on healthy lifestyles and
05:22quality of life after cancer
05:28and we welcome her tonight.
05:30Doctor Lesburg is an Associate
05:33Professor of Medical Oncology and
05:37the Director and Chief of the
05:41Breast Medical Oncology Division.
05:43She. Received her medical degree
05:46from the University of Maryland,
05:48where she completed her residency and
05:50she went on to complete a fellowship
05:53in Medical Oncology and Breast Medical
05:55Oncology at the Ohio State University
05:58before joining the faculty there in 2010.
06:00And she also earned the master's in
06:03Public health Public health from the
06:06Ohio State University in 2013. Her.
06:11Her he's been recognized for her
06:15patient focused care with awards,
06:17multiple awards and including being
06:22rated by Forbes is one of the top breast
06:25medical oncologists in the nation.
06:27She has an emphasis on improving
06:30longterm outcomes for patients
06:31with breast cancer who.
06:33Develop side effects associated with
06:35treatments and is doing novel and
06:38really exciting research on novel
06:40blood based biomarkers to identify
06:43recurrence and toxicity of treatment.
06:46Earlier she worked,
06:47she's an NCI funded investigator active
06:51in cancer cooperative group research
06:53and she collaborates widely with
06:56researchers from around the world and
06:58she really thrives in creating innovative.
07:00Multidisciplinary scientific teams,
07:05I'm going to turn that over
07:07to Doctor Brown to introduce
07:10Doctor Williams. Good, thanks.
07:12And and I'll just echo my welcome
07:15to everybody as well and to stress
07:19how important all of this is.
07:22Our relationship in primary care,
07:24new cancer is kind of an emergency.
07:28And and knowing that our Smile O
07:30team kind of has our backs and is
07:32able to help with that transition is
07:34is really important and we continue
07:37to work at doing that even better.
07:39And even though this talk is about
07:41kind of the other end where we're
07:43passing patients back to primary care.
07:46So it is my pleasure to introduce
07:48Doctor Brian Williams,
07:49a close colleague and friend.
07:52He is the Medical Director of
07:54Clinical Informatics within the
07:55Northeast Medical Group and one of
07:58the medical information officers
08:00offer EPIC in the system.
08:02His passion is streamlining clinical
08:04care to support both employee
08:07and clinician Wellness as well as
08:10patient experience and efficiency.
08:13He is an active primary care clinician
08:17in Mystic and where he serves
08:20with his wife in the same office.
08:23He's fortunate to serve as a medical
08:26director on in the beginning of
08:28his career at the How Come while?
08:31Oh no,
08:32it's a Health Center in Hawaii from
08:352005 till 2010 and that was where he
08:38learned from a visionary leadership team.
08:41On where integrating the electronic
08:43medical record and clinical
08:45quality programs had such potential
08:47to make patient care better.
08:50He subsequently came here East
08:52and was the Medical Director of
08:55Informatics at the LNM Medical
08:57Group through through 2016 when that
08:59group merged with Northeast Medical
09:01Group and he then became part of our
09:04informatics and clinical program.
09:07He graduated from the University
09:08of Colorado Health Science Center
09:10and completed his family.
09:11And us since the University of
09:13Texan in Austin, in Austin, TX.
09:17And Brian will actually start
09:19off the presentation with Case.
09:25Thank you, Dr. Brown. I'm so
09:27sorry to throw you the curveball.
09:29It's Hamakua Health Center.
09:32Thank you for the correction.
09:34Absolutely. Yeah.
09:35That's a tough one, but a beautiful place.
09:38And I'm really pleased to have been asked
09:40to participate in this particular topic.
09:42I think this you know survivorship
09:44sits squarely at the intersection
09:46of what our colleagues and oncology
09:48do and what we do in primary care.
09:51And I think this is, this is an area
09:53where more information is better.
09:57It's frequently I think a
10:00little bit vague in terms of.
10:02Concrete information that's
10:03available for us to kind of guide
10:05our decision making and care.
10:06So I'm really looking forward
10:08to this session.
10:08So we're going to kick it off with Case one,
10:12which is a 76 year old male that had
10:16a 60 pack year smoking history who
10:20presented in June of 2019 with complaints
10:22of increased difficulty swallowing.
10:24He was having a hard time getting food down.
10:27He was subsequently diagnosed
10:29with a squamous cell carcinoma.
10:31That affected the base,
10:32the left side of the base of his tongue.
10:35So during July and August of that year,
10:37he received definitive conformal radiation
10:40therapy with concurrent weekly cisplatin.
10:43He tried tolerated treatment quite well
10:46and had complete response to the tumor,
10:48fortunately,
10:48so since that time he's been followed
10:51every six months by his oncologist.
10:53And there's been no evidence of recurrence.
10:55But he missed his last followup appointment
10:57and in fact would rather not ever have
11:00to see a doctor again in his life.
11:02He has some residual longterm
11:03effects of treatment,
11:04including dry mouth and
11:06chronic neck stiffness,
11:07but overall doing well with no
11:09evidence of disease at the present.
11:12Go on to the next slide.
11:13So he presents today for his annual
11:16Wellness visit to his primary care.
11:18No ongoing concerns other than
11:20the usual aches and pains and the
11:23continued stable neck stiffness.
11:25He is stoic, though.
11:26This guy spends all of his time out on
11:29his fishing boat and in his garage working.
11:32He doesn't like doctors and he
11:33doesn't want to see anyone.
11:34He doesn't have to.
11:37So the questions associated
11:38with this case are first of all.
11:41What is survivorship?
11:42So I'm going to openly admit that
11:44this was a concept that was new
11:46to me approaching this webinar.
11:47And so I'm really glad that we're sharing
11:50about this because it's something
11:51that I found to be quite important.
11:54Second question,
11:54follow up is what kind of surveillance
11:57guidelines are there for high risk
11:59patients in general and maybe a little
12:01bit of specifics about this particular
12:03patient since this is a high risk cancer?
12:06And then a final question we're
12:08going to answer is what is the
12:10Smile of Survivorship clinic in
12:12which patients are appropriate
12:13for referral to this clinic?
12:15With that I'll turn it over to Doctor Sam.
12:20Thanks Brian. Coming off of five
12:23days of conferencing in Chicago,
12:26so forgive my hoarse voice.
12:28Really pleased to be here with all of
12:30you tonight and I see many familiar
12:32names on the participants list,
12:34so a shout out to my friends in the audience.
12:39But if we start with the definition,
12:42the NCI defines a cancer survivor
12:44as anyone who's been diagnosed with
12:47cancer and it starts at the time of
12:50diagnosis and extends through the
12:52balance of the individual's life.
12:56In that context, every patient
12:58who's ever been diagnosed with
13:01cancer is considered a survivor.
13:04And if you go to the next slide,
13:08there are three phases of survivorship,
13:11which I like to just briefly touch on.
13:14This was defined by a physician who
13:17had cancer and then wrote this article
13:19in the New England Journal in 1985.
13:22And he characterized these three phases
13:24as acute, extended and permanent,
13:26but I I renamed permanent to long term.
13:30The acute phase is really in
13:32that first diagnostic period.
13:33Probably Karen, like when you said
13:35this isn't an emergency like that is
13:37when you're going over the waterfall,
13:40you've just been diagnosed,
13:42there's lots of tests and imaging
13:44and you see an oncologist and
13:46surgeons and radiation doctors and
13:48you're going to have a treatment
13:50plan and you're in treatment.
13:52And the whole cancer community.
13:53Most a lot of times your whole
13:56support community comes together
13:57to carry you through this time,
13:59if you click through the animations here,
14:02the next period is the extended period
14:06which should be highlighted and then
14:09another Click to show the picture.
14:11I love this picture.
14:12I don't know if it's real,
14:13but you know the extended period
14:16starts after treatment is over.
14:18So usually treatments about.
14:21Maybe six months if you get chemotherapy,
14:24maybe a little less if it's not,
14:27maybe you might be on some maintenance
14:29therapy for the whole year.
14:30But generally in that,
14:32in that after that six months of
14:35really heavy going over the waterfall
14:37though the waters are calmer,
14:39but you're pretty sure the patients
14:41are pretty sure every something
14:42is going to get them every
14:44ache and pain is a recurrence.
14:47They might be dealing with
14:49their side effects.
14:50They might have a lot of post
14:52traumatic stress type symptoms.
14:54So they feel like they're it's a
14:58high uncertainty and that's where our
15:00clinic often comes in and I'm going to
15:02talk about that in in a few minutes.
15:03You click through the next animations.
15:072 more, one more click.
15:08So in long term survivorship.
15:10This is when the the waters
15:12are much more peaceful,
15:14the risk of recurrence goes down,
15:16but the late and longterm effects serve
15:19as a reminder of what you've been through.
15:22And so for each of these phases,
15:24survivors can have different needs.
15:26And I I think that's,
15:27you know,
15:28one of the reasons why can be so
15:30hard to wrap our minds around
15:32survivorship as a field because it
15:35really encompasses so much time.
15:37Next slide, please.
15:40There are certain themes that tie
15:44every single survivor together.
15:47So there's we can unify each unique
15:49person and they have a common set
15:52of of needs that need to be met.
15:54And this is simplification,
15:56but but we all agree that every
16:00survivor needs surveillance for
16:02both recurrence and a new cancer.
16:06And in general,
16:08at least in that first extended period,
16:11the oncologists want to be doing
16:14that kind of surveillance and and
16:16patients want their oncologists to
16:18be doing that kind of surveillance.
16:20As time goes on,
16:22that surveillance might get less frequent,
16:26less necessary and the needs of
16:28those survivors might change.
16:30And who who needs to do that?
16:32And then every survivor needs
16:34identification and treatment
16:35of late and longterm effects.
16:38And we can talk about incidence
16:39of all of that and different
16:41risks that would cause that,
16:43but we are all charged with
16:46identifying and addressing those.
16:49And then the topic of health promotions,
16:51what I personally is near and dear
16:54to my heart because there's very few
16:56times in an adult life where you're
16:58willing to change your behavior
16:59and cancer is often one of those.
17:01And so.
17:02Really using that teachable moment
17:05to help patients meet their goals
17:08for their diet, their exercise,
17:10maybe not drinking as much as they used to.
17:14Smoking cessation,
17:15especially in head and neck
17:17cancer patients as we know,
17:18can be so important.
17:19Every patient,
17:20but those are tenants of of
17:23survivorship care for everyone and
17:25then of course why we're here is.
17:28That we owe it to our patients to
17:29coordinate this care and make sure that
17:31nothing is falling through the cracks,
17:32which is so much easier said than done.
17:36Next slide,
17:36please.
17:39I was going to plug in this gentleman's.
17:45Profile on an app that I thought
17:47was available and show you like how
17:49we would solve this together if you
17:51didn't have a survivorship clinic.
17:53And I I don't know what happened to the app.
17:56I couldn't find it.
17:57So in head and neck cancer patients for
18:00instance if you Google survivorship and
18:03the American Cancer Society is a wonderful
18:06resource for both doctors and patients,
18:08you're going to get a PDF of guidelines and
18:11if you even click on the link that says.
18:14You know, a simple chart.
18:16This is one page on the left
18:19hand side of a three page chart.
18:22This is for head and neck cancer survivors.
18:24There's also the same information
18:26for breast cancer survivors,
18:28colon cancer survivors,
18:29prostate cancer survivors.
18:31And that's kind of where a Ch that's like
18:33a CS American Cancer side of the where
18:36their guidelines are sort of fitting.
18:38So instead I just summarized sort of what
18:41is in this document on the right hand side.
18:44So again it's a three page table.
18:46You'll see that there are
18:49recommendations for surveillance,
18:50screening and early detection
18:52of second primary cancers.
18:53They really call that out here because
18:55that's a particularly high risk in the
18:57head and neck cancer world because of
18:59the treatment that's given and the risk
19:02factors that are often associated with it.
19:04Then Assessment of Management
19:06of Physical and Psychosocial,
19:08Longterm and Late Effects.
19:09I listed those down there at the bottom.
19:12And then of course Health
19:13Promotion and Care Coordination.
19:15If you look at the list of late and
19:17longterm effects and you read the chart,
19:20every single one recommends that
19:22you primary care screen for each
19:25of these things detect and refer.
19:28And I feel overwhelmed just reading
19:30through that chart and can't imagine
19:33what it's like in a busy primary
19:35care clinic to maybe have that
19:37sense of duty to try to detect and
19:39treat and refer for specialized
19:42treatment for all of these issues.
19:44So I just, you know, curious on,
19:46on any comments on that,
19:48but this is what's in the
19:50literature right now.
19:51Next slide please.
19:54There is also you can find this on
19:55the American Cancer Society website.
19:57There is a link to this Cancer
20:00Survivorship e-learning series and
20:02there is a one hour webinar that focuses
20:06on head and neck cancer survivorship.
20:09What I was hoping to show is how you
20:11could figure all of this out in a few
20:13minutes and and it really I think
20:15illustrates the fact that it this is hard.
20:18I don't know how many people have an
20:20hour and a preparation for a patient to
20:22go and watch this to learn more about
20:24addressing this particular patient's needs.
20:27Next slide please.
20:30So I'm ending with just two slides
20:32about the Yale Survivorship Clinic.
20:37We have been around longer than I've
20:39been at Yale so it was started by
20:42a cancer survivor in 2006. He he.
20:48Explicitly said this is what I wished
20:50I had had in my cancer treatment.
20:52So this is what this is the team you
20:54must assemble if you want my money.
20:57And so Yale said Okay,
20:59we serve patients of all diagnosis.
21:03Any patient who's had a diagnosis of
21:06cancer is welcome to come to our clinic
21:09and we meet once weekly and we go to
21:12the different various greater New Haven.
21:16Locations. So we see patients in Smila,
21:18but we also go to Guilford,
21:20North Haven and Derby starting next month.
21:23Just a minute, I'm I'm going to call, sorry.
21:26I'm also have a couple kids hanging around.
21:28We give just a minute honey. Okay.
21:31All right, I'll, I'll help you.
21:33Amelia, can you help her get some food?
21:36We see patients for a one time
21:39consultation and then we usually have
21:41one or two follow up visits so we
21:44do not assume care of our patients.
21:46But they do get a 2 hour visit each
21:49time with four specialists and I'll
21:51tell you about them in just a minute.
21:54I think it's important to understand
21:56we do not take the place of either the
21:58oncologist or the primary care provider,
22:00but we do meet the patient where
22:02they are at and we provide a lot
22:05of individualized counseling and
22:07references based on what the survivor
22:09is hoping to achieve.
22:10And every single patient gets an
22:13individualized survivorship care plan.
22:15Next slide please. Okay.
22:16So who's the team?
22:18So I'm the medical director.
22:20I do see patients,
22:21but really the bulk of the patients are
22:24seen by my fabulous physicians assistant,
22:26Kevin Bretta,
22:27who would have loved to have
22:28been here tonight,
22:29but he's actually on a vacation
22:31and we want him to enjoy that.
22:34He he's the PA there in the top left,
22:36and he's the one who makes
22:39those survivorship care plans.
22:41He's the one who's making
22:43sure patients aren't lost.
22:44Can transition that they're that he
22:47that they understand you know what
22:49the plan is going forward who's
22:51going to be doing what and you know
22:53he addresses late and longterm
22:55effects from a medical perspective.
22:57The LCSW licensed clinical social
23:01worker is next to that.
23:03Right now it's Kristen Clark.
23:05They have our social workers have
23:07the highest level of training in
23:09their field for cancer and they
23:12really talk about the.
23:14Psychosocial aspects of coping with cancer
23:16and and so for instance back to this case.
23:18You know many of our head
23:20and neck cancer patients,
23:21though this man is stoic,
23:22he may be having some fear of eating.
23:25Could be that he's doing less socially
23:28because he's afraid of choking in
23:30public because of his chronic dry mouth.
23:32So this is would be an example
23:34of what the social worker might
23:36talk about and try to plug him in.
23:39With some help to to cope with
23:41that and and
23:43to validate those feelings and and
23:45maybe even treat anxiety and depression.
23:49Our physical therapist is a is actually
23:52also the head of our ank rehab program
23:55Scott Caposa and he is got he actually
23:58wrote the board of questions for
24:01the ACSM oncology certification for
24:03his for physical therapist. So he's.
24:06Been doing this for a very long time
24:08and he helps patients either get
24:10back to the physical functioning
24:13that they had before or maybe start
24:15a new plan to help meet new goals.
24:18And then of course as a PT he would be
24:21able to assess for this gentleman hit,
24:24you know, his range of motion,
24:26his ability to to stretch his neck.
24:29He would be able to prescribe a
24:31home exercise program to help with
24:34any symptoms that he's having.
24:36In his affected fields and then
24:39our last provider is a registered
24:41dietitian who's also a certified
24:43specialist in oncology.
24:44So again the highest levels of
24:46their of their field in cancer care.
24:49And right now we have a new dietitian
24:52named Natalie Smith and they
24:55really address you know not only
24:57weight gain and weight loss.
24:58So in this particular gentleman probably
25:00he's lost some weight through his
25:02treatment and possibly gaining that
25:04weight back can be really challenging.
25:06And lots of wellintentioned family
25:08members may have told him that all
25:10these supplements that he needs
25:12to take to prevent recurrence.
25:13And our dietitian really addresses
25:16myths about nutrition and cancer,
25:19of which there are many because the diet
25:21industry is a billion dollar industry.
25:26If we forget if there's one more slide,
25:30that's it. So I we.
25:34We would be happy to see any
25:37patient that you felt could benefit
25:39from what I just described.
25:41It doesn't matter if they're within
25:42that year or maybe they're three
25:44years and and sometimes we've even
25:47gotten patients who are 10 years out.
25:49And we we also try to face
25:51our patients every year.
25:53There's June is cancer survivorship
25:55month and we try to go directly to
25:58patients with webinars just like this
26:01to address issues and this will be our.
26:04I think our 4th June,
26:06that's virtual and it starts tomorrow.
26:08Now I'll just say that you can find this on
26:12our website if you yourself are curious.
26:14If you wanted to send a patient,
26:16they're going to be every Wednesday
26:18in June from 6:30 to 8:00 tomorrow.
26:20We start with a panel talking about
26:23restoring your body to integrity
26:26after cancer and on June 14th
26:29living with cancer chronically.
26:30On June 21st cancer and the family.
26:34How to advocate for your loved one And
26:36on June 28th, myths and social media.
26:40So thank you very much for your time.
26:42Oh, thank you.
26:44And yeah,
26:45I'll stop there.
26:47We do
26:47have a time. We do
26:48have time for a few questions,
26:50A couple of questions for Dr. Samt.
26:55And you can put them in the, the,
26:58the chat or you can actually.
27:01I think you have to put them to
27:02the chat, actually. Or the Q&amp;A.
27:09So Dr. Sam is I'm going to
27:11just ask a quick question.
27:13Is there space for those of us in
27:15primary care to communicate with you
27:18offline just in terms of recommendations
27:20around particular patient cases?
27:24Absolutely, we would, I mean we would
27:27love to consult on any questions or
27:29issues that are coming through or even.
27:34Listen and help find the answers.
27:36If we are not like immediately got them
27:39on on the nose we because of what we do,
27:42we do know where to find these answers.
27:45Probably quicker than a Google
27:48search and certainly quicker than the
27:50time you have to try to to look and
27:53figure it out so you know my e-mail.
27:55Is tara.samptatyale.edu Jeff and Britta
27:59is my PA and this is his full time job
28:02outside of helping with some of the
28:06breast patients that we see together.
28:08But this is where this is where
28:09we spend all of our time.
28:11We'd be happy to to consult offline and
28:13then help plug patients in as needed.
28:16Yeah, I I really, truly appreciate that
28:20and you know it in in primary care.
28:24We're I think frequently overwhelmed
28:27with the number of recommendations and
28:30items that we have to pay attention to.
28:33And you know all the things we
28:34have to juggle with patients and
28:36knowing that we can kind of lean on
28:37you as colleagues is very helpful.
28:39You know, to me I think that the two big
28:42takeaways for this case are first that.
28:45You know, patients with certain cancers
28:47are at much higher risk for other cancers.
28:49And actually I've, you know,
28:50I've also learned that frequently
28:52their rate of appropriate screening
28:54is lower than the general population,
28:56which is surprising.
28:57But I think something for us to
29:00all to keep in mind.
29:01And the second thing is,
29:02is that there are, you know,
29:03great resources in place to help guide
29:05kind of care decisions for these patients.
29:09I'm curious the way.
29:11You know Dr. Williams, you set this up.
29:13Is this this gentleman really
29:15didn't want anymore followup,
29:18even though, you know,
29:19he probably needed ongoing surveillance,
29:21at least from primary care and and
29:24maybe also from oncology or ENT.
29:26Would would a trip to the survivorship
29:30clinic kind of been something that
29:32would help him to understand why or help
29:34him kind of come to closure on this?
29:36How would it have worked,
29:38you know, in this particular case?
29:41So given that this is a real patient
29:44that I hope quite well, there's not
29:47a prayer that he would ever go.
29:52He's he's a lovely gentleman,
29:53but he's let's just say that he's a
29:56tried and true New Englander little
29:58rough around the edges, you know,
30:01in this case, access for me.
30:03To some of these providership resources
30:05is going to be very beneficial because
30:08I can help guide him and we sort of have
30:12that ongoing connection even though he's
30:14never all that fond of even seeing me.
30:16But you know,
30:17that's a in this particular instance,
30:19that's a very helpful thing.
30:21I think other cases,
30:23definitely your suggestion
30:24that that might help,
30:26you know give him the context to
30:28think about this going down the road,
30:29it would be very beneficial.
30:31Can I just quickly comment on that?
30:33You know, there's we see
30:35men and women, you know,
30:37probably about 300 per year total that.
30:39So there's lots of people that don't
30:41make it into us for whatever reason.
30:44They either don't know or they don't
30:45want to or they don't think they need us.
30:47Often times for men,
30:50wives bring them or children bring them and
30:53really you know it is kind of a little bit.
30:56Against their will in some ways.
30:58The reason why we have 4 specialists there,
31:00including a social worker and
31:02you see every single one is to
31:05really give that space that yeah,
31:06you would never have agreed to
31:08see a social worker and talk about
31:09how you're coping with cancer.
31:11But when it's built in,
31:13it's shocking how therapeutic it
31:15can be and how much people say,
31:17I didn't know that I really how
31:19much I really needed that. So.
31:22So I appreciate all those points.
31:24One
31:25more question from Jill Banatowski and
31:28that is you know the role of community
31:31PT versus this specific PT is there,
31:34is there kind of handoff,
31:36is there something special about it?
31:39Yes and yes. So the cancer ank rehab
31:43is a is a specialized field and and
31:46our patients really do many of them
31:49do need someone who understands the.
31:51You don't want somebody who's going
31:54to be manipulating something that's
31:55not right and then cause more harm.
31:58Thankfully though,
32:00many of the P T's in Connecticut are
32:03extremely reputable and experienced
32:04and local physical therapies. Fine.
32:06What we do is we first try to get Scott
32:09to see the patient in clinic and then he
32:11knows all of these providers and he'll say,
32:14oh, in your area.
32:15This person,
32:16she's even lymphedema specialized,
32:17so she could even assess you for head
32:20and neck lymphedema, for instance.
32:21And you know,
32:22often times he'll even make the connection
32:25through e-mail or something like that.
32:27So, so yes and yes,
32:29local is fine and a rehab specialist
32:32can be really helpful to get
32:34the ball rolling and especially
32:36ours who maintain relationships
32:37with people all over the state
32:41been fantastic.
32:41Thank you Tara so much.
32:43And I, I know you have a
32:45family commitment to get to.
32:46So thanks for joining us and
32:49we'll move to the to the second.
32:52Case here. Thanks again,
32:59one that'll be close to many of our hearts.
33:00So it's a 71 year old female with
33:04medical history significantly
33:05for hypertension which is well
33:07controlled and hyperlipidemia.
33:08She was diagnosed at age 62 with
33:10right sided breast cancer that
33:12was an invasive ductal carcinoma.
33:14It was Grade 1 anatomic stage 1A estrogen
33:18and progesterone receptor positive,
33:19hair 2 new negative.
33:21So she was treated with the right
33:23mastectomy and a subsequent
33:25prophylactic left side of mastectomy
33:27and bilateral reconstruction.
33:29She continues to be followed by
33:31oncology annually and has been
33:33maintained on Mastrozole without
33:35any evidence of recurrence.
33:37She's very active.
33:38She stays healthy,
33:39takes care of herself,
33:40exercises daily good diet.
33:41Then we'll go on to the next slide.
33:48So she presented with subacute onset
33:51of localized mid lumbar back pain.
33:54Her pain was localized to the
33:56L23 region of the mid back.
33:58She described it as an ache with a
34:00maximum intensity of four out of 10.
34:02Gets worse when she's exercising and walking.
34:05It troubles her a little bit in bed as well.
34:07There's no other symptoms
34:09associated with this,
34:10and no bowel or bladder complaints.
34:13Her physical exam was largely unremarkable.
34:15She's not tender.
34:16In the area where she localizes her pain
34:19and her neurologic exam was non revealing.
34:22So the questions we might ask
34:24in this case include you know,
34:25how do we approach new complaints
34:27that may be related to cancer and
34:30maybe harbingers of recurrence and
34:32specifically in this situation,
34:34how common is recurrence in breast cancer?
34:40Thank you Brian for for
34:42for overview of that case.
34:44Hi everyone. Thank you.
34:46For joining out of your busy evening,
34:49as you heard, I've been treating breast
34:52cancer patients for a number of years and
34:55very thrilled to be speaking with you.
34:58So the question is,
35:00you know how often do you do recurrences
35:03happen in in breast cancer and we we tend
35:07to see two peaks of recurrences where
35:09we have an early peak of recurrences.
35:12That can happen in the first
35:14three to five years.
35:15In this particular case,
35:16if you remember,
35:17she's in her 9th year and she has this
35:22hormone receptor positive breast cancer.
35:24Late recurrences can happen sometimes
35:28more than five years or sometimes
35:30decades from the initial diagnosis,
35:32and these are more common in hormone
35:36receptor positive breast cancers
35:38where they're more favorable.
35:40But they also tend to have this
35:42period of dormancy where even if all
35:44the right treatments have been done,
35:46patients have done all the right things,
35:49we could see recurrences that
35:51happen here down the road.
35:53So next to the next slide,
35:57press one more time for this, yes, so.
36:00Kind of give you a little bit more about
36:05how common these late recurrences are.
36:08They're very much proportionate to the
36:11initial risk of the of the disease.
36:14In the yellow line,
36:16you see lymph node negative breast cancer,
36:18which was this particular patient's case.
36:21And as you can see, you know,
36:23five years, even up to 10 years,
36:27the rate of death from breast
36:29cancer can be quite low.
36:30However, as time passes,
36:32a proportion of these patients can actually
36:35progress to metastatic breast cancer,
36:38which is the predominant way that
36:40individuals from breast cancer actually.
36:43Die from breast cancer.
36:44It's not from early stage disease,
36:45it's from metastatic breast cancer.
36:47In the blue and red lines you can see how
36:51patients who have higher stages of disease,
36:54lymph node positive disease,
36:56then the curves are very steeply rising.
37:00For example,
37:01half of the patients who who had a
37:05number of lungs not positive disease,
37:08this would fall into the stage 3 category.
37:11Can potentially recur,
37:13sometimes several decades after
37:15initial diagnosis.
37:17So when we see those media campaigns
37:20saying breast cancer caught early is
37:23a curable disease, it absolutely is.
37:26But a lot of those fear statistics and
37:30American Cancer Society statistics are
37:32geared toward these first five years.
37:36However, what what,
37:37what our data are not showing is what
37:39can happen several decades later.
37:41So it can be actually quite hard
37:44for patients because the campaign
37:45has been just do what you're told,
37:48get your mammogram, get your treatments.
37:49And this is curable and treatable.
37:51And when these recurrences happen,
37:53it can be extremely
37:56psychologically traumatic.
37:57So next slide.
38:00So this patient, you know,
38:02had had some back pain.
38:03This is your bread and butter.
38:05You see, I'm sure multiple patients
38:07during the day present with back pain.
38:09And in no way are we suggesting that
38:13just because she has this distant
38:15history of breast cancer that you
38:18necessarily deviate from your standard
38:20algorithmic workup and your good
38:23clinical judgment of having taken
38:25care of patients for many years.
38:28But, but just I think the point of this
38:30case is that that you know that this,
38:32this history of breast cancer,
38:34even though it's almost nine years
38:36does raise the suspicion that it could
38:39possibly be related to metastatic
38:41breast cancer and to at least have
38:43that on the differential and an
38:46unexplained pain that doesn't go away.
38:50So let's say you do all your good
38:52primary care work up and conservative
38:55measures and she's not improving.
38:57I think what we would like to avoid
38:59for patients with with for example,
39:00this type of history is to perhaps
39:03raise that index of suspicion
39:04a little sooner or so,
39:06so that they would get a little bit of
39:07a closer work up sooner than a patient,
39:09let's say without a history of breast cancer.
39:12So pain is the one of the most
39:14common presentation of these
39:16types of distant recurrences,
39:17I tell my patients.
39:19As a human,
39:20you are going to have aches and pains.
39:22You're going to have back pain,
39:23you're going to have shoulder pain
39:25and knee pain.
39:25Not every sign of pain is a sign of cancer,
39:28but if something is persisting
39:30and not responding to these
39:32conservative measure measures,
39:34then then these patients should
39:35be absolutely worked up more.
39:37Shortness of breath and cough are also
39:40another more common presentation where again,
39:42you know people are going to cough,
39:45but if it's just not going away and
39:47lingering that that raises the suspicion
39:49that something more should be done.
39:51A vague abdominal pain can sometimes
39:53be be one of the initial presentation
39:55of liver metastases and breast cancer,
39:58and in the red box is this very general.
40:02Description that I also share
40:04with my patient,
40:05which is that any symptom that you're worried
40:08about that cannot be easily explained.
40:10I think we want to at least have
40:12have have our index of suspicion up.
40:15Thanks.
40:17And you know it's this partnership that
40:20the theme that we've been focusing
40:22on and we're so grateful that you're
40:25here so we can have this conversation.
40:28Patients often feel very lost in
40:31these junctures where they they they
40:33kind of don't know who to turn to
40:35and as much as we can do to show
40:38that we're partners that we are,
40:40I think it can be so helpful in terms
40:42of the anxiety and I apologize in a
40:45public setting, sorry for the background.
40:47So, so just the idea of this that we
40:50are triad together, working together
40:52to to to expedite the work up,
40:55these are the things that are really,
40:57really important.
40:58To patients next slide.
41:00And so just reemphasizing that
41:02this is a super vulnerable time.
41:06There are often a feeling of betrayal.
41:09There can be even some anger toward
41:12the original oncologist that
41:13diagnose them because we celebrated
41:15that they're cured with them we.
41:18There's a sense of why wasn't
41:20this found earlier.
41:20I went to my PCP and I complained
41:22about this two months ago.
41:24Why wasn't this worked up?
41:25So these are not that anybody
41:27did anything wrong,
41:28but I think it's that time of
41:31vulnerability for these patients.
41:33Obviously healthcare systems are
41:36very complicated and it it takes
41:40time to schedule testing.
41:41We completely understand that.
41:43But just just all of us being really
41:45cognizant that given half five anxiety
41:48state is for these patients when
41:50they're worried about potential recurrence.
41:52Anything we can do to even move
41:55things up by a day or two really goes
41:57a long way in terms of rebuilding
42:00trust within the healthcare system
42:02and making making them feel heard.
42:04And the the last point I've already said,
42:07but it's really important to repeat
42:09it which is the more we communicate
42:11with one another as as a primary care.
42:14Writers and oncologists,
42:15it is so absolutely reassuring to patients,
42:18so,
42:19so in this particular case it may have
42:21been a bread and butter musculoskeletal
42:24back pain or maybe something else,
42:28but but bone metastases are actually
42:31the most common presentation of receptor
42:33positive breast cancer metastases.
42:35So we wanted to.
42:38Kind of highlight that as as one
42:40of the more common presentations
42:42of test suites for this group.
42:50Thank you Doctor Lustberg and
42:51thanks for joining from the airport.
42:53I know that it's really over and
42:55above it's one other note that I just
42:58wanted to make about this particular
42:59case is you know this patient really
43:01took the heart the recommendations
43:03around self-care she know at the
43:05time of her diagnosis she really.
43:08Let's just say made some very
43:11appropriate and long lasting lifestyle
43:13adjustments and those do impact
43:15like longer term risk of recurrence
43:17and also risk of other health
43:21conditions and other primary cancers.
43:24So case 3, this is lung cancer and a
43:27video visit an 85 year old female.
43:30Without a significant past medical
43:32history that was diagnosed in 2019 with
43:35a non small cell adenocarcinoma of the
43:37right lung that was metastatic to her brain.
43:40So she was enrolled in the clinical
43:43trial in November of that year with
43:46pembrolizumab plus bevacisumab for
43:48asymptomatic brain metastases 4
43:51cycles of the combination followed
43:53by pimbolism and monotherapy.
43:54She completed a total of 34 cycles every
43:57three weeks which was tolerated quite well.
44:00And responded very well.
44:01And she's been followed by oncology since
44:04that time without evidence of recurrence
44:06and still remains in good health.
44:09And go to the next slide.
44:10So she presents today for a video
44:13visit complaining of nausea and
44:14vomiting for five days.
44:16She's been having a hard
44:17time keeping food down.
44:19She tested herself at home
44:21and was positive for COVID.
44:23So she continues to have nausea currently
44:26and is able to keep sips of water down.
44:29But she's not complaining of any
44:31other symptoms relatable to the COVID,
44:33such as congestion, cough,
44:34shortness of breath.
44:36She does feel achy all over and chilled,
44:39but no fever.
44:41Her physical exam limited,
44:42of course, by the video visit,
44:44but she appears mildly ill,
44:46but not emergently ill.
44:47She's alert and oriented and answers
44:49all of our questions appropriately.
44:51She doesn't appear to be short of breath,
44:53speaking in complete sentences,
44:54and there's no cough noted during her visit.
44:57Her mucous membrane, she sticks out
44:59her tongue and her tongue is moist.
45:01So that's good news.
45:03So a few questions related to this case.
45:07How do we monitor patients that are
45:09very high risk for recurrence and
45:11how do we approach patients with an
45:14acute illness that have a higher risk
45:17of complications of that illness?
45:18And then finally,
45:20what other options are there for
45:22patients to address survivorship in general?
45:27Thank you, Brian.
45:29So this case was selected to really
45:32highlight a few important points which
45:35is that advances in cancer treatment,
45:38particularly immunotherapy have
45:40dramatically improved survivorship
45:42outcomes in patients with lung
45:45cancer as well as Melanoma.
45:47So, so now we're seeing.
45:49Longterm survivors of these very serious
45:52malignancies who who are doing well,
45:55but they may have some complications
45:57related to the to the original cancer
46:00diagnosis or or to their treatments.
46:03So patients who are higher risk and
46:06have known metastatic disease typically
46:08depending on the type of malignancy,
46:12they are routinely followed
46:14with serial scans and so.
46:17So in this particular case patient
46:18had a known brain metastasis where
46:20her brain would be serially monitored
46:23and her body would be monitored.
46:24In other malignancies.
46:26Other types of surveillance modalities may
46:29be used such as bone scans and PET scans.
46:33You're going to see in your practice
46:36patients being surveillanced differently
46:38based on their type of cancer and where
46:41they are in their disease course and.
46:44In terms of symptoms,
46:46so, so,
46:47so often these patients with more
46:49advanced illness may get additional
46:51scans based on the new symptoms.
46:53So for example,
46:54a breast patient who may not be
46:56normally getting brain Mri's if she's
46:59suddenly reporting a headache that
47:02may necessitate additional imaging.
47:04Patient preference partially weighs in in
47:07terms of her surveillance some patients.
47:10Really are extremely anxious and about
47:12scans and if they've been stable for a
47:15very long time with advanced disease,
47:18we may actually lower the
47:19frequency of the scans.
47:21And then there are some patients who are
47:23be reassured on scans or if they're on
47:26a clinical trial that may necessitate
47:28additional scan frequency next,
47:33is it moving forward?
47:36And so with with our newer treatments,
47:39a lot of these patients with more
47:41advanced disease and reemphasizing the
47:43point made by doctor staff is that the
47:46definition of a survivor does not exclude
47:49patients with more advanced illness.
47:51So they're all survivors from
47:53day one of diagnosis throughout
47:55the balance of their life.
47:57So so but they may be on ongoing
47:59treatment and the checkpoint
48:00inhibitors which are the predominant
48:03immunotherapy costs that we're using
48:04in a range of malignancies can have
48:07many types of immune related cities
48:10and they may present your primary
48:12care office with symptoms that.
48:15You'll be kind of wondering is this
48:18an immune related toxicity or is it
48:21a common that just just a regular
48:23old symptom that may be unrelated.
48:25So these are the challenges that we all face.
48:27Is it related to cancer,
48:29is it related to cancer treatment
48:31or is it something else?
48:32There's also a range of oral targeted
48:35therapies that are now actively being used.
48:38So patient can essentially take a pill
48:41therapy that is specifically targeting
48:43a protein or antigen on their tumor.
48:46And again, impressive results
48:49in terms of treatment efficacy,
48:52but they can have a range of
48:53side effects including fatigue,
48:55rash, metabolic issues.
48:55So this is what we need your help with.
48:58So if they're developing hyperglycemia
49:00on these agents for example,
49:02we absolutely need your partnership
49:04to better these.
49:05Thanks.
49:08And so there's lots of resources
49:09in terms of toxicity management.
49:11And I think this may be a separate
49:14webinar if there's interest on this.
49:16But one thing I've highlighted
49:18because you will be seeing a lot of
49:20immunotherapy complications in the
49:21practice is that the American Society
49:24of Clinical Oncology guidelines for
49:26immunotherapy are readily available
49:28and it's a really good solid resource.
49:32Also, don't be afraid to reach out to us.
49:34Again, we're not asking you guys
49:36to be immunotherapy experts,
49:37but you just have that index of
49:39suspicion of if these patients are on
49:42targeted therapies or immunotherapy
49:43agents that some of the things that
49:45may seem routine may actually be
49:47related to the cancer treatment next.
49:51And then this was a really important
49:54article that really launched.
49:56An expansion of how we see survivorship,
49:58which is that patients with metastatic
50:01cancer, again, it fits the NCI definition.
50:04But for a long time as a community,
50:07we have sort of felt that, oh,
50:10it's it's only for patients with curable
50:11disease, which is absolutely false.
50:14And so Tom Smith and Terry Longbaum wrote
50:18this really wonderful article that was
50:20published in 2019 in the Journal of Medicine.
50:23Really highlighting a lot of the
50:26similarities and differences that can
50:28happen in the related to survivorship,
50:31related concerns in patients
50:32who are in remission.
50:34Kind of in that extended or
50:36longterm phase that you saw Dr.
50:38Dr.
50:38Singh talking about where patients
50:40who are actually living with cancer.
50:42And as you can see that could be
50:44physical issues, emotional issues,
50:46sexual health issues.
50:48There's actually more similarities
50:49than differences in terms of some
50:51of the domains of survivorship.
50:53So, so this is,
50:54this is an area that that we would
50:56love to partner with you to help
50:58support these patients that are
51:00actively being seen in both primary
51:02care as well as oncology offices and
51:06all of the survivorship resources
51:08that we've been talking about are
51:10available for these patients as well.
51:12Thanks.
51:14And so kind of coming back to the
51:17to those patients with who've had
51:19incredible responses to immunotherapy,
51:21there is not a body of literature
51:24really talking about the experience of
51:26how these patients actually feel after
51:29essentially being being told that,
51:31you know, you have advanced illness.
51:33We're not sure how long you have to live.
51:36And then because of the advanced
51:38advent of immunotherapy,
51:39they're actually living years
51:41and years after diagnosis.
51:43So there's a body of work developed.
51:44Working in terms of the this
51:46particular study showed that they feel
51:48like they live in a twilight zone.
51:50They feel like they're they're between the
51:52edge of death and the living and they not,
51:55they're not quite sure where they fit in.
51:57So kind of in the coming years you're
51:59going to see more of this type of work
52:02coming out where we're beginning to
52:04understand better the needs of these
52:06survivors with advanced illness next.
52:09So I want to make sure we
52:10have time for your questions.
52:12So just wanted to just highlight
52:14a few quick takeaways,
52:15which is that patients would advance
52:17cancer like this particular case,
52:20she may have just had COVID or she
52:22may have had COVID plus possibly
52:25a recurrence of her cancer.
52:27I think it's it's the,
52:28it's the differential that we
52:30all would think about.
52:32Brain metastasis recurrence
52:33can also present with nausea,
52:35vomiting and not not the malaise
52:38and not being able to eat so.
52:41So just kind of keeping that
52:43differential why it is important
52:45quality of life and symptom management
52:48is particularly important in these
52:50patients living with advanced illness and
52:53coordination of care with you guys is.
52:56Even more important in these patients
52:58with more complicated cancers on
53:00ongoing treatment and as much as we
53:02can regularly communicate the matter.
53:04So I'll stop there and make sure
53:06we have time for some questions.
53:08Thank you.
53:11There
53:17are no questions
53:18from the audience yet.
53:19So if you're listening,
53:20please enter questions after
53:23Williams. Do you have any?
53:24I do have a question.
53:26So the, you know immunotherapy is
53:29is a really recent occurrence and
53:32I think many of us in primary care
53:36don't have a tremendous number of
53:39patients that have actually received
53:41immunotherapy like the ones we discussed.
53:44What's the time horizon for
53:46us to be alert for potential?
53:50Adverse effects from those
53:52from those treatments,
53:53is it mostly during the treatment
53:55window or is it something that concur
53:58kind of longer subacute or even kind
54:01of great question, Dr. Williams.
54:03So so the majority of these would
54:06be first picked up on if that is
54:09more of an acute reaction while
54:12patients are receiving immunotherapy.
54:14Thyroid dysfunction issues for example
54:17are extremely common and we actually,
54:20if you wonder why is that oncologists
54:22checking thyroid function,
54:23that's what I do.
54:25It's actually part of our chemo plans
54:28to actually be checking thyroid
54:30function and adrenal function
54:32because these toxicities can be so,
54:34so, so common.
54:37Pneumonitis and cardiac issues
54:39are a little less common,
54:41but it's something that we if the
54:43patient is presenting with with
54:45shortness of breath during treatment
54:47or really any type of cardiac issue,
54:49the cardiac immune related
54:50toxicity can actually be deadly.
54:53That's not picked up early so so
54:55you're going to see if you see your
54:57oncologist doing certain types of
54:59work up that you're you're kind
55:00of like well cardiac work up it
55:02should be something I would be
55:04doing it's it's it's related to
55:06kind of kind of that that that
55:08high index of suspicion for these
55:11immunotherapy toxicities rashes are
55:13really common with immunotherapy
55:15as well as targeted therapies.
55:17So so so so so that's that's something
55:20that's very commonly seen and then we.
55:23I also worry a lot about colitis,
55:26immune related diarrhea where we
55:29typically if we're worried about it,
55:32we would have to hold the immunotherapy
55:35typically start high dose steroids and
55:38you can imagine if somebody already
55:41has metabolic syndrome or diabetes.
55:44All the things that you guys are expert at,
55:46we can kind of get into the cycle
55:48of trouble where we're struggling
55:50these hyper steroids and then their
55:52blood sugars are spiking etc.
55:53So that's another point where good
55:56close communication is super important.
55:58But to answer your question,
55:59most of the time these toxicities
56:02do happen during treatment,
56:05but then the endocanopathies that
56:07happen during immunotherapy do
56:08not necessarily go away after
56:10the immunotherapy is over.
56:12So,
56:12so we're sort of.
56:14The patients are left to continue
56:16to manage those complications.
56:18That's helpful. That's really helpful.
56:20So is it safe to say that you know,
56:21should a patient who's actively undergoing
56:24immunotherapy present with symptoms
56:26that could possibly really related,
56:29it would be important for us to get a hold
56:31of the treating oncologist immediately?
56:33Yes, yes. And I think I think
56:37pretty much from head to toe.
56:40Any organ can be involved in,
56:43in terms of immune related toxicity.
56:45So absolutely this is exactly we
56:49would want to hear from you and we
56:52are not expecting you to be the
56:55sole clinician managing these,
56:57but even alerting us that
56:59occasion is having trouble.
57:00They may have called you before
57:02they called us and I think
57:03that's why it's important.
57:07Well, I think we've run out of time.
57:10I just wanted to say that last patient
57:12was my patient and she's doing well,
57:14she just had COVID.
57:16So that was good news.
57:18But just wanted to to again thank
57:21you all for for participating
57:23this time and throughout the year.
57:25Please write something in the survey
57:27about it just because we can get
57:29your feedback as we just as we
57:30try to figure out what to do next
57:33year and and then I'll just hand
57:35it over to to Karen to to close.
57:40Just want to thank everybody
57:41for their attendance.
57:43Thank the panelists for their
57:45preparation and thoughtful
57:47approach to these issues.
57:49And actually and I want to
57:51thank you because it's the end
57:53of our first year doing this.
57:55So we will have a little
57:57celebration together,
57:58which does not mean we
57:59won't have recurrence.
58:03All right, good. Thank you all, everybody.
58:06Thanks, Brian. Thanks, Miriam.
58:10Yeah.