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Dr. Hope Rugo and Dr. Kamaria Lee discuss the prevalence of financial toxicity in cancer care in the United States and globally, focusing on breast cancer, and highlight key interventions to mitigate financial hardship. TRANSCRIPT  Dr. Hope Rugo: Hello, and welcome to By the Book, a podcast series from ASCO that features engaging conversations between editors and authors of the ASCO Educational Book. I'm your host, Dr. Hope Rugo. I'm the director of the Women's Cancer Program and division chief of breast medical oncology at the City of Hope Cancer Center, and I'm also the editor-in-chief of the Educational Book. Rising healthcare costs are causing financial distress for patients and their families across the globe. Patients with cancer report financial toxicity as a major impediment to their quality of life, and its association with worse outcomes is well documented. Today, we'll be discussing how patients with breast cancer are uniquely at risk for financial toxicity. Joining me for this discussion is Dr. Kamaria Lee, a fourth-year radiation oncology resident and health equity researcher at MD Anderson Cancer Center and a co-author of the recently published article titled, "Financial Toxicity in Breast Cancer: Why Does It Matter, Who Is at Risk, and How Do We Intervene?" Our full disclosures are available in the transcript of this episode.  Dr. Lee, it's great to have you on this podcast. Dr. Kamaria Lee: Hey, Dr. Rugo. Thank you so much for having me. I'm excited to be here today. I also would like to recognize my co-authors, Dr. Alexandru Eniu, Dr. Christopher Booth, Molly MacDonald, and Dr. Fumiko Chino, who worked on this book chapter with me and did a fantastic presentation on the topic at ASCO this past year. Dr. Hope Rugo: Thanks very much. We'll now just jump into the questions. We know that rising medical costs contribute to a growing financial burden on patients, which has [GC1]  [JG2]  been documented to contribute to lower quality-of-life, compromised clinical care, and worse health outcomes. How are patients with breast cancer uniquely at risk for financial toxicity? How does the problem vary within the breast cancer population in terms of age, racial and ethnic groups, and those who have metastatic disease? Dr. Kamaria Lee: Breast cancer patients are uniquely at risk of financial toxicity for several reasons. Three key reasons are that breast cancer often requires multimodal treatment. So this means patients are receiving surgery, many receive systemic therapies, including hormonal therapies, as well as radiation. And so this requires care coordination and multiple visits that can increase costs. Secondly, another key reason that patients with breast cancer are uniquely at risk for financial toxicity is that there's often a long survivorship period that includes long-term care for toxicities and continued follow-ups, and patients might also be involved in activities regarding advocacy, but also physical therapy and mental health appointments during their prolonged survivorship, which can also add costs. And a third key reason that patients with breast cancer are uniquely at risk for financial toxicity is that the patient population is primarily women. And we know that women are more likely to have increased caregiver responsibilities while also potentially working and managing their treatments, and so this is another contributor. Within the breast cancer population, those who are younger and those who are from marginalized racial/ethnic groups and those with metastatic disease have been shown to be at an increased risk. Those who are younger may be more likely to need childcare during treatment if they have kids, or they're more likely to be employed and not yet retired, which can be disrupted while receiving treatment. And those who are racial/ethnic minorities may have increased financial toxicity due to reasons that exist even after controlling for socioeconomic factors. And some of these reasons have been shown to be increased risk of job or income loss or transportation barriers during treatment. And lastly, for those with metastatic breast cancer, there can be ongoing financial distress due to the long-term care that is needed for treatment, and this can include parking, transportation, and medications while managing their metastatic disease. Dr. Hope Rugo: I think it is really important to understand these issues as you just outlined. There has been a lot of focus on financial toxicity research in recent years, and that has led to novel approaches in screening for financial hardship. Can you tell us about the new screening tools and interventions and how you can easily apply that to clinical practice, keeping in mind that people aren't at MD Anderson with a bunch of support and information on this but are in clinical practice and seeing many, many patients a day with lots of different cancers? Dr. Kamaria Lee: You're exactly right that there is incredible nuance needed in understanding how to best screen for financial hardship in different types of practices. There are multiple financial toxicity tools. The most commonly used tool is the Comprehensive Score for Financial Toxicity, also known as the COST tool. In its full form, it's an 11-item survey. There's also a summary question as well. And these questions look at objective and subjective financial burden, and it uses a five-point Likert scale. For example, one question on the full form is, "I know that I have enough money in savings, retirement, or assets to cover the cost of my treatment," and then patients are able to respond "not at all" to "very much" with a threshold score for financial toxicity risk. Of course, as you noted, one critique of having an 11-item survey is that there's limited time in patient encounters with their providers. And so recently, Thom et al validated an abbreviated two-question version of the COST tool. This validation was done in an urban comprehensive cancer center, and it was found to have a high predictive value to the full measure. We note which two questions are specifically pulled from the full measure within the book chapter. And this is one way that it can be easier for clinicians who are in a busier setting to still screen for financial toxicity with fewer questions. I also do recommend that clinicians who know their clinic's workflow the best, work with their team of nurses, financial navigators, and others to best integrate the tool into their workflow. For some, this may mean sending the two-item survey as a portal message so that patients can answer it before consults. Other times, it could mean having it on the tablet that can be done in the clinic waiting room. And so there are different ways that screening can be done, even in a busy setting, and acknowledging that different practices have different amounts of resources and time. Dr. Hope Rugo: And where would people access that easily? I recognize that that information is in your chapter, or your article that's on PubMed that will be linked to this podcast, but it is nice to just know where people could easily access that online. Dr. Kamaria Lee: Yes, and so you should be able to Google ‘the COST measure', and then there is a website that also has the forms as well. So it's also beyond the book chapter, Googling ‘the COST measure', and then online they would be able to find access to the form. Dr. Hope Rugo: And how often would you do that screening? Dr. Kamaria Lee: So, I think it's definitely important that we are as proactive as possible. And so initially, I recommend that the screening happens at the time of diagnosis, and so if it's done through the portal, it can be sent before the initial consult, or again, however, is best in the workflow. So at the time of diagnosis and then at regular intervals, so throughout the treatment process, but then also into the follow-up period as well to best understand if there's still a financial burden even after the treatments have been completed. Dr. Hope Rugo: I wonder if in the metastatic setting, you could do it at the change of treatment, you know, a month after somebody's changed treatment, because people may not be as aware of the financial constraints when they first get prescribed a drug. It's more when you hear back from how much it's going to cost. And leading into that, I think it's, what do you do with this? So, you know, this cost conversation is really important. You're going to be talking to the patient about the cost considerations when you, for example, see that there are financial issues, you're prescribing treatments. How do we implement impactful structured cost conversations with our breast cancer patients, help identify financial issues, and intervene? How do we intervene? I mean, as physicians often we aren't really all that aware, or providers, of how to address the cost. Dr. Kamaria Lee: Yes, I agree fully that another key time when to screen for financial toxicity is at that transition between treatments to best understand where they're at based off of what they've received previously for care, and then to anticipate needs when changing regimens, such as like you said in the metastatic setting. As we're collecting this information, you're right, we screen, we get this information, and what do we do? I do agree that there is a lack of knowledge among us clinicians of how do we manage this information. What is insurance? How do we manage insurance and help patients with insurance concerns? How do we help them navigate out-of-pocket costs or even the indirect costs of transportation? Those are a lot of things that are not covered in-depth in traditional medical training. And so it can be overwhelming for a lot of clinicians, not only due to time limitations in clinic, but also just having those conversations within their visit. And so what I would say, a key thing to note, is that this is another area for multidisciplinary care. So just as we're treating patients in a multidisciplinary way within oncology as we work with our medical oncology, surgical colleagues across the board, it's knowing that this is another area for multidisciplinary care. So the team members include all of the different oncologists, but it also includes team members such as financial counselors and navigators and social workers and even understanding nonprofit partners who we have who have money that can be set aside to help reduce costs for certain different aspects of treatment. Another thing I will note is that most patients with breast cancer often say they do want to have these conversations still with their clinicians. So they do still see a clinician as someone that can weigh in on the costs of their treatment or can weigh in on this other aspect of their care, even if it's not the actual medication or the radiation. And so patients do desire to hear from their clinicians about this topic, and so I think another way to make it feel less overwhelming for clinicians like ourselves is to know that even small conversations are helpful and then being knowledgeable about within your institution or, like I said, outside of it with nonprofits, being aware of who can I refer this patient to for continued follow-up and for more detailed information and resources. Dr. Hope Rugo: Are those the successful interventions? It's really referring to financial navigators? How do people identify? You know, in an academic center, we often will sort of punt this to social workers or our nurse navigators. What about in the community? What's a successful intervention example of mitigating financial toxicity? Dr. Kamaria Lee: I agree completely that the context at which people are practicing is important to note. So as you alluded to, in some bigger systems, we do have financial navigators and this has been seen to be successful in providing applications and assisting with applications for things such as pharmaceutical assistance, insurance applications, discount opportunities.  Another successful intervention are financial toxicity tumor boards, which I acknowledge might not be able to exist everywhere. But where this is possible, multidisciplinary tumor boards that include both doctors and nurses and social workers and any other members of the care team have been able to effectively decrease patients' personal spending on care costs and decrease co-pays through having a dedicated time to discuss concerns as they arise or even proactively. Otherwise, I think in the community, there are other interventions in regards to understanding different aspects of government programs that might be available for patients that are not, you know, limited to an institution, but that are more nationally available, and then again, also having the nonprofit, you know, partnerships to see other resources that patients can have access to.  And then I would also say that the indirect costs are a significant burden for many patients. So by that, I mean even parking costs, transportation, childcare. And so even though those aren't interventions necessarily with someone who is a financial navigator, I would recommend that even if it's a community practice, they discuss ways that they can help offset those indirect costs with patients with parking or if there are ways to help offset transportation costs or at least educate patients on other centers that may be closer to them or they can still receive wonderful care, and then also making sure that patients are able to even have appointments scheduled in ways that are easier for them financially.  So even if someone's receiving care out in the community where there's not a financial navigator, as clinicians or our scheduling teams, sometimes there are options to make sure if a patient wants, visits are more so on one day than throughout the week or many hours apart that can really cause loss of income due to missed work. And so there are also kind of more nuanced interventions that can happen even without a financial navigation system in place. Dr. Hope Rugo: I think that those are really good points and it is interesting when you think about financial toxicity. I mean, we worry a lot when patients can't take the drugs because they can't afford them, but there are obviously many other non-treatment, direct treatment-related issues that come up like the parking, childcare, tolls, you know, having a working car, all those kinds of things, and the unexpected things like school is out or something like that that really play a big role where they don't have alternatives. And I think that if we think about just drug costs, I think those are a big issue in the global setting. And your article did address financial toxicity in the global setting. International financial toxicity rates range from 25% of patients with breast cancer in high-income countries to nearly 80% in low- and middle-income countries or LMICs. You had cited a recent meta-analysis of the global burnout from cancer, and that article found that over half of patients faced catastrophic health expenditures. And of course, I travel internationally and have a lot of colleagues who are working in oncology in many countries, and it is really often kind of shocking from our perspective to see what people can get coverage for and how much they have to pay out-of-pocket and how much that changes, that causes a lot of disparity in access to healthcare options, even those that improve survival. Can you comment on the global impact of this problem? Dr. Kamaria Lee: I am glad that you brought this up for discussion as well. Financial toxicity is something that is a significant global issue. As you mentioned, as high as 80% of patients with breast cancer in low- and middle-income countries have had significant financial toxicity. And it's particularly notable that even when looking at breast cancer compared to other malignancies around the world, the burden appears to be worse. This has been seen even in countries with free universal healthcare. One example is Sri Lanka, where they saw high financial toxicity for their patients with breast cancer, even with this free universal healthcare. But there were also those travel costs and just additional out-of-hospital tests that were not covered. Also, literature in low- and middle-income countries shows that patients might also be borrowing money from their social networks, so from their family and their friends, to help cover their treatment costs, and in some cases, people are making daily food compromises to help offset the cost of their care. So there is a really large burden of financial toxicity generally for cancer globally, but also specifically in breast cancer, it warrants specific discussion. In the meta-analysis that you mentioned, they identified key risk factors of financial toxicity globally that included people who had a larger family size, a lower income, a lack of insurance, longer disease duration, so again, the accumulation of visits and costs and co-pay over time, and those who had multiple treatments. And so in the global setting, there is this significant burden, but then I will also note that there is a lack of literature in low-income countries on financial toxicity. So where we suspect that there is a higher burden and where we need to better understand how it's distributed and what interventions can be applied, especially culturally specific interventions for each country and community, there's less research on this topic. So there is definitely an increased need for research in financial toxicity, particularly in the global setting. Dr. Hope Rugo: Yes, and I think that goes on to how we hope that financial toxicity researchers will have approaches to large-scale multi-institutional interventions to improve financial toxicity. I think this is an enormous challenge, but one of the SWOG organizations has done some great work in this area, and a randomized trial addressing cancer-related financial hardship through the delivery of a proactive financial navigation intervention is one area that SWOG has focused on, which I think is really interesting. Of course, that's going to be US-based, which is how we might find our best paths starting. Do you think that's a good path forward, maybe that being able to provide something like that across institutions that are independent of being a cancer only academic center, or more general academic center, or a community practice? You know, is finding ways to help patients with breast cancer and their families understand and better manage financial aspects of cancer care on a national basis the next approach? Dr. Kamaria Lee: Yes, I agree that that is a good approach, and I think the proactive component is also key. We know that patients that are coming to us with any cancer, but including breast cancer, some of them have already experienced a financial burden or have recently had a job loss before even coming to us and having the added distress of our direct costs and our indirect costs. So I think being proactive when they come to us in regards to the additional burden that their cancer treatments may cause is key to try to get ahead of things as much as we can, knowing that even before they've seen us, there might be many financial concerns that they've been navigating.  I think at the national level, that allows us to try to understand things at what might be a higher level of evidence and make sure that we're able to address this for a diverse cohort of patients. I know that sometimes the enrollment can be challenging at the national level when looking at financial toxicity, as then we're involving many different types of financial navigation partners and programs, and so that can maybe make it more complex to understand the best approaches, but I think that it can be done and can really bring our understanding of important financial toxicity interventions to the next level. And then the benefit to families with the proactive component is just allowing them to feel more informed, which can help decrease anticipation, anxiety related to anticipation, and allow them to help plan things moving forward for themselves and for the whole family. Dr. Hope Rugo: Those are really good points and I wonder, I was just thinking as you were talking, that having some kind of a process where you could attach to the electronic health record, you could click on the financial toxicity survey questions that somebody filled out, and then there would be a drop-down menu for interventions or connecting you to people within your clinic or even more broadly that would be potential approaches to manage that toxicity issue so that it doesn't impact care, you know, that people aren't going to decide not to take their medication or not to come in or not to get their labs because of the cost or the transportation or the home care issues that often are a big problem, even parking, as you pointed out, at the cancer center. And actually, we had a philanthropic donor when I was at UCSF who donated a large sum of money for patient assistance, and it was interesting to then have these sequential meetings with all the stakeholders to try and decide how you would use that money. You need a big program, you need to have a way of assessing the things you can intervene with, which is really tough. In that general vein, you know, what are the governmental, institutional, and provider-level actions that are required to help clinicians do our best to do no financial harm, given the fact that we're prescribing really expensive drugs that require a lot of visits when caring for our patients with breast cancer in the curative and in the metastatic setting? Dr. Kamaria Lee: At the governmental level, there are patient assistant programs that do exist, and I think that those can continue and can become more robust. But I also think one element of those is oftentimes the programs that we have at the government level or even institutional levels might have a lot of paperwork or be harder for people with lower literacy levels to complete. And so I think the government can really try to make sure that the paperwork that is given, within reason, with all the information they need, but that the paperwork can be minimized and that there can be clear instructions, as well as increased health insurance options and, you know, medical debt forgiveness as more broad just overall interventions that are needed. I think additionally, institutions that have clinical trials can help ensure that enrollment can be at geographically diverse locations. Some trials do reimburse for travel costs, of course, but sometimes then patients need the reimbursement sooner than it comes. And so I think there's also those considerations of more so upfront funds for patients involved in clinical trials if they're going to have to travel far to be enrolled in that type of care or trying to, again, make clinical trials more available at diverse locations.  I would also say that it's important that those who design clinical trials use what is known as the “Common Sense Oncology” approach of making sure that they're designed in minimizing the use of outcomes that might have a smaller clinical benefit but may have a high financial toxicity. And that also goes to what providers can do, of understanding what's most important to a particular patient in front of them, what outcomes and what benefit, or you know, how many additional months of progression-free survival or things like that might be important to a particular patient and then also educating them and discussing what the associated financial burden is just so that they have the full picture as they make an informed decision. Dr. Hope Rugo: As much as we know. I mean, I think that that's one of the big challenges is that as we prescribe these expensive drugs and often require multiple visits, even, you know, really outside of the clinical trial setting, trying to balance the benefit versus the financial toxicity can be a huge challenge. And that's a big area, I think, that we still need help with, you know. As we have more drugs approved in the early-stage setting and treatments that could be expensive, oral medications, for example, in our Medicare population where the share of cost may be substantial upfront, you know, with an upfront cost, how do we balance the benefits versus the risk? And I think you make an important point that discussing this individually with patients after we found out what the cost is. I think warning patients about the potential for large out-of-pocket cost and asking them to contact us when they know is one way around this. You know, patients feeling like they're sort of out there with a prescription, a recommendation from their doctor, they're scared of their cancer, and they have this huge share of cost that we didn't know about. That's one challenge, and I don't know if there's any suggestions you have about how one should approach that communication with the patient. Dr. Kamaria Lee: Yes, I think part of it is truly looking at each patient as an individual and asking how much they want to know, right? So we all know that patients, some who want more information, some want less, and so I think one way to approach that is asking them about how much information do they want to know, what is most helpful to them. And then also, knowing that if you're in a well-resourced setting that does have the social workers and financial navigators, also making sure it's integrated in the multidisciplinary setting and so that they know who they can go to for what, but also know that as a clinician, you're always happy for them to bring up their concerns and that if it's something that you're not aware of, that you will connect them to the correct multidisciplinary team members who can accurately provide that additional information. Dr. Hope Rugo: Do you have any other additional comments that you'd like to mention that we haven't covered? I think the idea of a financial toxicity screen with two questions that could be implemented at change of therapy or just periodically throughout the course of treatment would be a really great thing, but I think we do need as much information on potential interventions as possible because that's really what challenges people. It's like finding out information that you can't handle. Your article provides a lot of strategies there, which I think are great and can be discussed on a practice and institutional level and applied. Dr. Kamaria Lee: Yeah, I would just like to thank you for the opportunity to discuss such an important topic within oncology and specifically for our patients with breast cancer. I agree that it can feel overwhelming, both for clinicians and patients, to navigate this topic that many of us are not as familiar with, but I would just say that the area of financial toxicity is continuing to evolve as we gather more information on most successful interventions and that our patients can often inform us on, you know, what interventions are most needed as we see them. And so you can have your thinking about it as you see individual patients of, "This person mentioned this could be more useful to them." And so I think also learning from our patients in this space that can seem overwhelming and that maybe we weren't all trained on in medical school to best understand how to approach it and how to give our patients the best care, not just medically, but also financially. Dr. Hope Rugo: Thank you, Dr. Lee, for sharing your insights with us today. Our listeners will find a link, as I mentioned earlier, to the Ed Book article we discussed today in the transcript of this episode. I think it's very useful, a useful resource, and not just for providers, but for clinic staff overall. I think this can be of great value and help open the discussion as well. Dr. Kamaria Lee: Thank you so much, Dr. Rugo. Dr. Hope Rugo: And thanks to our listeners for joining us today. Please join us again next month on By the Book for more insightful views on topics you'll be hearing at Education Sessions from ASCO meetings and our deep dives into new approaches that are shaping modern oncology. Thank you. Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Follow today's speakers:       Dr. Hope Rugo  @hope.rugo  Dr. Kamaria Lee @ lee_kamaria Follow ASCO on social media:       @ASCO on X (formerly Twitter)       ASCO on Bluesky      ASCO on Facebook       ASCO on LinkedIn       Disclosures:      Dr. Hope Rugo:   Honoraria: Mylan/Viatris, Chugai Pharma  Consulting/Advisory Role: Napo Pharmaceuticals, Sanofi, Bristol Myer  Research Funding (Inst.): OBI Pharma, Pfizer, Novartis, Lilly, Merck, Daiichi Sankyo, AstraZeneca, Gilead Sciences, Hoffman La-Roche AG/Genentech, In., Stemline Therapeutics, Ambryx    Dr. Kamaria Lee: No relationships to disclose  

Texas surgeon Dr. Elisabeth Potter says UnitedHealthcare stopped her mid-surgery to question if the patient's procedure was necessary – despite the fact the patient was already on the operating table. Dr. Potter was even threatened with legal action after sharing her astonishing story on social media. The health insurance giant denies that it would ever ask a doctor to interrupt care. But this incident follows an alarming pattern with UnitedHealthcare. According to Daily Mail, “UnitedHealthcare has also been accused of using an AI program with a 90 percent error rate to deny claims.” “Without insurance,” the Mail says the surgery being performed by Dr. Potter “costs anywhere from $30,000 to $50,000.” The Mail also reports a spokesperson from UnitedHealthcare claimed “There are no insurance related circumstances that would require a physician to step out of surgery… We did not ask nor would ever expect a physician to interrupt patient care to answer a call.” Dr. Elisabeth Potter details UnitedHealthcare's legal threats against her for speaking out. Dr. Eric Weiss shares his pioneering work in stem cell therapy for autism, drawing from his son's journey and a suppressed CDC study showing a 1135% autism increase linked to thimerosal in vaccines. Dr. Elisabeth Potter is a board-certified plastic surgeon who earned her MD from Emory University and completed a fellowship at MD Anderson. She specializes in natural breast reconstruction, performing over 1,000 DIEP flap surgeries. Formerly a regulatory analyst of FDA law, she monitors BIA-ALCL risks. Follow at https://x.com/epottermd Dr. Eric Weiss is board-certified in plastic surgery and a leader in regenerative medicine. Founder of North Florida Stem Cells Clinic, he treats autism with stem cell therapy. He co-authored Educating Marston, a memoir about his son's autism journey. Follow at https://instagram.com/northfloridastemcells 「 SUPPORT OUR SPONSORS 」 Find out more about the brands that make this show possible and get special discounts on Dr. Drew's favorite products at ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠https://drdrew.com/sponsors⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠  ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠• FATTY15 – The future of essential fatty acids is here! Strengthen your cells against age-related breakdown with Fatty15. Get 15% off a 90-day Starter Kit Subscription at ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠https://drdrew.com/fatty15⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ • PALEOVALLEY - "Paleovalley has a wide variety of extraordinary products that are both healthful and delicious,” says Dr. Drew. "I am a huge fan of this brand and know you'll love it too!” Get 15% off your first order at ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠https://drdrew.com/paleovalley⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ • VSHREDMD – Formulated by Dr. Drew: The Science of Cellular Health + World-Class Training Programs, Premium Content, and 1-1 Training with Certified V Shred Coaches! More at https://drdrew.com/vshredmd • THE WELLNESS COMPANY - Counteract harmful spike proteins with TWC's Signature Series Spike Support Formula containing nattokinase and selenium. Learn more about TWC's supplements at ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠https://twc.health/drew⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ 「 MEDICAL NOTE 」 Portions of this program may examine countervailing views on important medical issues. Always consult your physician before making any decisions about your health. 「 ABOUT THE SHOW 」 Ask Dr. Drew is produced by Kaleb Nation (⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠https://kalebnation.com⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠) and Susan Pinsky (⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠https://twitter.com/firstladyoflov⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠e⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠). This show is for entertainment and/or informational purposes only, and is not a substitute for medical advice, diagnosis, or treatment. Learn more about your ad choices. Visit megaphone.fm/adchoices

In this episode of the IC-DISC show, I sit down with Ronak Shah to discuss his transition from a corporate career at Intel to entering the scrap metal business, to founding a successful scrap metal business in New Caney, Texas. We talk about the motivation behind his career shift and the mentors who guided him along the way. Ronak opens up about the challenges he faced while transitioning from a large corporate environment to a smaller, more hands-on business. We also explore Ronak's decision to sell his business and the unexpected opportunities that arose from that choice. He reflects on the experiences gained throughout his career, emphasizing the importance of taking calculated risks and adapting to change. His story offers insights into the value of connecting past experiences to current ventures, even when the path isn't always straightforward. Finally, we discuss navigating today's fast-paced digital world and the importance of maintaining a low profile on social media. Ronak's journey highlights the balance between professional growth and personal fulfillment, making this episode a thoughtful exploration of entrepreneurship and resilience.     SHOW HIGHLIGHTS I explore Ronak's remarkable transition from a corporate role at Intel to establishing a successful scrap industry business in New Caney, Texas, emphasizing his desire for more tangible work and the influence of key mentors. The episode delves into Ronak's career progression at Schnitzer Steel and Alter Trading, where he gained critical insights in non-ferrous recovery and learned the importance of agile, smaller teams in driving technological advancements. Through journaling and introspection, Ronak clarifies his professional desires, leading to the creation of Levitated Metal and reflecting on personal challenges, including his late wife's battle with cancer. We discuss the financial strategies Ronak utilized in his entrepreneurial ventures, such as leveraging IC-DISC tax advantages and aligning financial decisions with personal values. The conversation highlights Ronak's leadership insights, his decision to pursue a smaller business for personal fulfillment, and the impact of selling his business on both his professional and personal life. Ronak shares reflections on his entrepreneurial journey, touching on the lessons learned from his career, the importance of taking risks, and the role of hindsight in connecting the dots of his experiences. The episode concludes with a discussion on navigating the complexities of the modern digital landscape and the importance of maintaining a low profile in a rapidly changing social media environment.   Contact Details LinkedIn - Ronak Shah (https://www.linkedin.com/in/ronakshahpdx/) LINKSShow Notes Be a Guest About IC-DISC Alliance About Levitated Metals Ronak ShahAbout Ronak TRANSCRIPT (AI transcript provided as supporting material and may contain errors) Dave: Hi Ronak, how are you today? Roank: Good David, Nice to see you again. Dave: Likewise, and where are you calling into from? Where are you in the world at the moment? Roank: I'm at my factory in New Caney, Texas, just a little bit northeast of Houston Great. Dave: Now are you a native Houstonian. Roank: I'm not, so I moved out here in 2019 to build this factory and start this business. I think I've been to Houston once in the prior year to visit for the first time and never before, other than perhaps through the airport. So, I didn't know a lot about Houston. I'm not saying that I know a lot about Houston now, but it's been a great place to build a business. It's been a fine place for my kids to grow up. Dave: It's been good it's been a fine place for my kids to grow up. It's still good. Yeah, it's. Uh, it's kind of a, it's kind of a hidden gem in a lot of ways. Uh, you know houston is, it's got a lot going for it that if your only experience is just driving through town or going through the airport, you know, I mean you hear traffic, humidity, heat, urbanl and you're just kind of like, you know, yeah, it doesn't sound like my kind of place. Roank: Yeah, well, it would be a lot more believable if you did not have a Breckenridge background behind you. Dave: True, yeah, that is the Breckenridge background for sure. So where did you grow up then, if you didn't grow up in Houston? Roank: I grew up in upstate New York so my dad was one of the many immigrants that came over in the late 60s, early 70s. They were looking for people with medical training and background. So he came over from India, lived in New York. I was born in New York City but very soon after grew up in the middle of the Finger Lakes. We moved to Syracuse when I was in middle school and then I went to Boston for undergraduate and I bounced kind of between Boston and London and back to Boston, then to Portland, oregon, which is where I came into the scrap industry and lived for some time in St Louis. I lived there for about nine years and from St Louis to here. Dave: Okay. So what made you get into the scrap business if you didn't have a family history in it? Roank: Yeah, it was just very random, my interest in the scrap industry. I think, the truth of the answer is probably the more interesting one. So after mba I was working, I was an operations guy and I was working at intel corporation in portland, near portland oregon, and loved being in portland. It's a fine place to live. But intel was, I mean, a huge company, right, 80 000 people, and just like the process of making something that was about this big, the the size of the core diet, multiprocessor, microprocessor this wasn't sufficiently interesting to me and I was too far from it, as well as my chain organization. Yeah. It didn't feel tangible enough, and so that was one part of it. But then the other part of it as well was you know I was there as a worker bee, you know, in a reasonably senior job for someone of my age, but then, you know, in a reasonably senior job for someone of my age, but then you know intel was having difficulty. So they bring in bane and company to kind of work on strategy or whatever and so two of the guys that I went to school with that, I knew well, were like literally working literally seven layers in the organization above me, and I'm like what? and so I just hit that, I tapped out, I extracted, I was like this is just some horse crap. I, this isn't the place for me. I need to go somewhere where I'm, you know, in a, in a smaller pod, where I can really touch and feel a thing. And so I just started throwing resumes out and wound up at Schnitzer Steel. Now really, yeah, and oh really. Yeah, and it was great. It was a time of transition for Schnitzer. I don't know if it was a great transition time for Schnitzer. They were transitioning from an older style scrap company to a more professional slash corporate company of the style that it is today. So they had parts of the parts of their business were both things and for sure I liked the old thing a lot and just tons of fun being in places like Boston and Portland scrapyard when they were building big mega shredders and new factories and driving the continuous improvement process there and trying to get metrics around things. It was really a good time. I enjoyed a lot of it. I came to Alter Trading in 2010 and that was wonderful right, I owe so much of my career everything I learned everything to the team at Alter, to Jay Rabinovitz and Rob and Michael Goldstein. I learned a lot there. I did a lot of really fun stuff for them that helped transform the company into the highly successful privately owned scrap company it is today. Dave: Like on the technology side, correct yeah. Roank: So I built a few factories, non-ferrous recovery plants to process not steel non-ferrous portions of the shredder and extract more metals out of stuff that would otherwise have gone to the landfill. And it was you know, exciting to do that, and it wasn't just building the factories but really growing out the entirety of the division that became, you know, a kind of center of excellence around that function, and it's an area that you know Alter remains very strong in today. Dave: Okay, well, I am excited to get into the next part of your story. So you're living in St Louis, working at Alter, being involved in some cool stuff and forward thinking technology. So how did from there? How do you end up starting a company in New Caney, texas? Roank: Yeah, so it's no reason not to be as open and honest about it as possible. So Alter was amazing. For the first six or seven years I was there, the job was like a nine and a half out of 10. I remember I was in New York going to make this time up sometime in 2013 or something like that. I've been there for three years and the Powerball was like some huge number, like a billion dollars, and so me and some buddies that were in finance, we all bought Powerball tickets and we talked about what we would do if we won the money, and I remember I determined to say I don't know if I would necessarily quit my job, right, like I really love what I do. I still think about that today. Dave: Did any of them have the same thought? Roank: No, they thought I was just completely crazy and they weren't necessarily wrong. I think I think perhaps again I loved it, but the point of it is I really enjoyed it. It was fulfilling, I had impact, things were changing. All of that when I struggled is as that phase of what Alter needed ended and I needed to move and assist alter with other things, primarily helping them grow a tier of management that had come from the art management level into being the next business leaders of the company. Just, you know, it's kind of standard transition planning type stuff and succession planning. I struggled with doing that successfully, a role that perhaps would have been viable or successful or satisfactory for me to do had it occurred during a standard line management. You know, hierarchical management structure was hard for me to find value in fulfillment, in and I would say success in doing. Yeah, as a matrix manager, you know, as a, as a guide, as a internal consultant. I just didn't love it. I hate to put it that way. I just sure, sure and at the same time, alter was going through a certain amount of a a ton of growth, right, a lot of growth that I participated in through acquisition and internal growth as well disbanded organic growth. But it was going through a lot of growth and so the company that felt small and familial at 40 yards suddenly felt just large and 70 for me. Dave: Too much like it felt too much like Intel. Roank: Nowhere near that level. There's nothing like that. It remains a really effective, well-directed company today. But, it felt different for me and I also realized that I wasn't good at that bigger company stuff. You know, my way of thinking about things didn't scale successfully to that level. I would not be the right guy at that level and this is an unfortunate thing to say. But I chose to. I did not want to change. You know, I thought about so. My boss for many years there was Jay Rabinowitz, who was, until he retired recently, the CEO of Alter Trade. He was fascinating. His ability to grow into the mindset required, the management rank that he was in at the time, or growing into, was phenomenal. And so a guy that if you only knew him 30 years ago was a rough and tumble scrap guy was and you've seen him on podcasts and things like that. It became and presents fully as and fills the shoes of a methodical, thoughtful, mature and a CEO who does a great job of leading A 1,200, 1,500 person organization. You would have never thought that if you only knew him 25 years ago perhaps, but his ability to grow was really phenomenal. For, by choice or by capability or whatever it was, I did not have or want that and so I wanted something dramatically smaller. Dave: Okay. Roank: And so I spent a bunch of time not just thinking about it but literally journaling about it. Because when you just think about these type of problems in your mind like hey, what do I want to do professionally? Yeah, you can just ping pong in your brain. And what I found helped me through the process was writing it down. And if you remember, back in high school, your English teacher would tell you to you know write a draft of the story, or an outline, and then a draft and then the final essay. I mean, I don't know about you, but I would never do any of that crap. But I did this time and I found that, like the first draft was, you know, just vomit on a page of orally thought out concepts and beliefs. And so I wrote it again and it was clear. And I wrote it again, it was clear. It helped me really understand what I liked and didn't like and what I wanted and didn't want from the next phase. And it was a time when, you know, my kids were just about to graduate middle school. If I was ever going to leave St Louis, this was the time to do it. It was not going to be easy. It was not easy for them to leave St Louis, but that's when. That's how I made that choice. I was uncertain as to what I would do. Right, I was out there both looking at shredder yards to buy as well as businesses. To start, I looked at a wire chopping plant. I ultimately built a heavy media plant. I did look at and made successful offers on a couple of different shredders, but none of that actually panned out and in the end I raised a bunch of money, moved out to Houston, built this thing. Dave: That is a great story and your kids ended up adjusting okay to, because I believe you live in one of the really nice master plan communities around Houston. Roank: Yeah, and they've adjusted well. I think my son is glad that we moved down here. My daughter is a little bit on the fence, but she was younger when we moved. Both my wife my late wife and I in many ways would have probably preferred where we lived in. Dave: St Louis, it was a small town in Kirkwood. Roank: You're familiar with it, but here it's been great. The Woodlands is a, you know, magical little bubble of a place to live. It's got everything you need. It's 25 minutes to the factory. All of it has been, from that perspective, just fine. When my wife got cancer, we were right here at MD Anderson. You know a lot of that stuff worked out. Dave: That is great. So tell me what your business premise was for Levitated Metal. So maybe give just a little background. What does the company do? Roank: Sure, so we're a heavy media flotation platform. What we do is we buy a thing called Sorba and we make aluminum Twitch. But stepping back from that to people that don't know what any of those words mean, our suppliers are the largest scrap metal processors in the region. Right, the states who will buy something like an old 2008 ford 500 sedan that's at the end of its life, yeah, shred it into fist size and smaller pieces, extract all the steel out with a magnet and then extract all the other metals like aluminum from the engine, copper, brass zinc, die, cast through other technologies. That aluminum, copper, brass zinc all is mixed up together in little pieces in a giant pile and that product is called a made up word Zorba by the industry. They make lots of it inside of houston. probably 15 million pounds to 18 million pounds of it is made every month right I buy that it's useless the way it is because you can't melt it, because it's got too many different types of metals in it and it doesn't make a useful alloy. But if you can get the aluminum out, that aluminum is super valuable because that aluminum you know used to be the engine block of a old car. It's a pretty tight chemistry match to the alloy required for the engine block of a ford f-150 a 2005. So through a density flotation process using water and ferrosilicon, we can change the density of that water so we can actually float the aluminum out. Dave: Hence the name levitated. Roank: Yeah, it's not a novel technology. I buy the equipment from some dude in Italy. There are well over 100 of these kind of plants in the world, maybe a little less than a dozen when levitators started up in the united states and a very what it sounds like a simple process is a royal pain in the rear. That actually managed because it's a very analog system with all sorts of weird chemistry and other things involved and a challenging plant to rot. But you know, we do a pretty decent job of it. Dave: Now, why did you pick New Caney, texas? I've been to St Louis, in fact, I was just there last month. They appear to have plenty of land around that place, you know, especially across the river in uh, is that illinois? That's just east so why? Didn't you just buy some land and do it up there? Roank: so where these plants, where the competitive plants exist, are relatively close to where their consumers, the aluminum smelters that would buy the recycled aluminum, are, and that's generally already in that area. So there are plenty of plants in that area. Dave: Okay. Roank: Down here in Houston. What was the case when I chose to move down here it became very quickly not the case, because two other people also built plants was that there was a large market in Mexico that did not have access to this type of material because there were no media plants in Texas or along the Mexican border. And aluminum manufacture in Mexico was growing incredibly well, much like the rest of their economy, and so what I saw was a consumer need right mexican heavy media plants, a set of suppliers in the texas area that did not have a domestic buyer for their zorba and so good supplier footprint and, at the time, a relative lack of competition. But I didn't realize. So, like two months after the financial raise was done and everything like that was, there were in fact, two more plants that were in the process of being built. They both started, you know, six to 12 months after mine did not so far away. There's one up near dallas, there's one up in arkansas so it became a little bit more competitive, though in truth that has not really changed the calculus on anything in a great way. It hasn't really improved the deal too much. Dave: Okay, and it was you started with, just a green field, right? Roank: Yeah, it was some trees and dirt and 10 acres. It was some trees and dirt and 10 acres and I started with dirt work and stormwater and concrete and buildings and equipment and built the whole thing. Dave: What year did you? Roank: start COVID 2020. Oh, it was the heck of a time. Dave: That was the construction was during COVID yeah. And when did you open? Roank: Then we started processing. At the end of December we shipped our first 2020 and we started shipping material in full January 2021. Dave: Oh wow, that really was in the midst of COVID. It was Most of it wasn't? Roank: that big a deal. There was some delay in equipment delivery because it came from Italy, and so if anybody had a rougher time COVID wise, it was Italy. So it came from Italy, and so if anybody had a rougher time COVID-wise, it was Italy. So it came from Italy but that might have only cost us a couple months. What was really frustrating and challenging and ultimately we were able to get through it was simply the difficulty of bringing process experts from Europe to the US during the COVID timeline. You know, like I can't tell you how many voicemails I left at the US embassy in Milan to sorry the US consulate in Milan to try to, you know, accelerate the review of the visa for the texts to come in from Italy, but I can tell you how many times somebody probably listened to it with zero, so just a royal pain in the rear. You know, just because the pain in the rear to get that all done, it got done. But those were challenging times. Dave: So started January of 2021 and, uh, at the time, had you given any thought to how long you might want to, that you and your investor group might want to run the business or own the business? Did you have any thought when you started it about what I honestly thought? I? Roank: would run it and own it for like nearly 10, 15 years years and grow it over time and continue to be in the space, et cetera, et cetera. It was meant to be a longer term cashflow, not one necessarily built on an exit strategy of selling at some point in the future. That was the original intent. Dave: How did that-year plan end up working out for you? Roank: Well, it turned out to be much shorter than that. So, as it turned out, in 2023, we had an unsolicited offer from Murfrees Industries to purchase the business assets. Dave: Wow, just two years later. Roank: Yeah, two years of operation later. Yeah, and for a number of reasons, it was the right choice for me and my investors to do the sale and it's been absolutely phenomenally good, I think, for both sides. The transaction itself, you know, from my perspective, great because you know it was an accelerated exit, but an exit nevertheless, and it still gives me the opportunity to continue to do the same job in the same office every day that I really enjoy doing that. I find great fulfillment and mental stimulation and sense of purpose in without the undeniable and underestimated stress of being a business owner. Dave: Yeah. Roank: So that's been absolutely great. It occurred at a time when my wife was battling cancer and took a lot of stress off. Taking that business stress off the table Sure Just made it easier to get through that entire process. Yeah, and it's just been a good. I think it's been fun for everybody. You know Adam and Michael Mervis were the you know fourth generation. Perhaps Adam and Michael Mervis we're the fourth generation perhaps owners of Mervis Industries enjoy having the levitated team in their company. We enjoy being part of it. Both of us have to do better together. It's been really just great. Dave: That is awesome, because not all transactions work out that well. Roank: Yeah, I'm sure there's some number out there that I would have sold the company at, knowing full well that I would not have wanted to work there afterwards. I'm sure there is, but I'm glad I didn't have to. Dave: Because you were I'm guessing you were the. Were you a minority shareholder? Did your? I was a minority shareholder. Roank: Oh, you were the majority, okay. Dave: So it was ultimately your call Correct and your but the the deal clicked, checked all the boxes and and were your investors disappointed that they were going to lose their cash flowing business. Roank: No, they were very pleased with the cash they got all up front. They were fine. That is great. Coincidentally, I did this math when we were doing the sale. I think that the net result of it was the same. Dave: IRR or plus or minus one within 1% of the IRR. Roank: That was in the financial presentation for the business itself. Really, yeah, very unexpected. Yeah, again, nothing more than a coincidence yeah what do you, what do you enjoy most? enjoy the most about the business is building and growing things. What I have realized is that is not sufficient to be a great leader. Right, there's building and growing things. A great leader right, there's building and growing things. But there's also all the other things that a leader should gain and find value in a business that I'm just not personally built to enjoy nearly as much. Right, I enjoy growing the skillset for the people that work for me. I enjoy seeing them be successful, but I don't think I enjoy it as much as I really should, or that a leader really should. In many ways, I think what I've discovered is I almost enjoy being an individual contributor more than. I enjoy being a leader and in in many ways, that's why I enjoy being at such a small company. Right, yeah, here the leadership I have to do is very direct. It's in the office, with people that are no more than 15 feet away from me right now. It's a very old style of working. You, you know, I have one remote employee and thank God she is very self-directed and capable and intelligent and proactive about reaching out to me, because otherwise she would be really disappointed and I would suck at that job. And so when we talk about you know what do we like about the job? I enjoy the improving of things. I enjoy the new thing to be done. That is not as much of it's not that much of running a business as you would want it to be. Sure, it's not like about a small business, though are just the variety of stuff I get to do I wear slightly fewer hats now than I did before the acquisition, but I was the CFO. I was, unfortunately, the lead IT guy, even though portions of these functions were outsourced as well. I sold all the metals. Having never sold a pound of metal in my life prior to levitated metals, I sold all the amount and then I was the president. I was the lead on any plant improvement projects of great size that we had again support throughout the organization on all these little pieces. But that's a lot of little hats to wear okay, okay. That a bigger company would have a head underneath every one of those hats. Sure, so I enjoy being able to do the breadth of those activities. I think it's rare that people can do the breadth of those activities. You and I talk about ICDIS stuff all the time and I would wager at a level that maybe less than five company owners that you interact with are able to discuss the situation. Is that probably correct, or am I? I think it's probably less than three yeah. Dave: And I can't think of who the other two are, so you might be in a class of your own. Roank: Yeah, I enjoy that thing right when I think about things that I would have been in a different life. Perhaps tax accountant could be one of those. But man, this is a very different life than tax accountant. Dave: Yeah for sure I think you made the right call. Well, as we're kind of rounding the home stretch, I've just got a few more questions. One is when you were leaving Intel, if you had a time machine, or maybe right after you left Intel and you had a time machine that you could go back and have a conversation with the younger Ronak 20 years ago, what might you have told yourself? What advice might you have had? Roank: or wisdom that you might've wanted to share. I don't think I would've shared anything. Dave: No, wouldn't want to, but I would've wanted that. Roank: With the exception my wife's death, there is not a single thing that I would have changed that is a you're. Dave: I asked that question on my guest and you're probably the only one who's ever answered it that way. Roank: So I would say, yeah, what type of things do people say? Oh, you know the number one, because I'm not just saying that because I don't want to watch other podcasts, I just yeah, well, no, I can give give you the rundown. Dave: The most common answer is they wish they would have taken a risk sooner. They wish they would have started their company sooner. They wish they'd been more willing to take a chance. Now, granted, many of my guests are self-made first-generation entrepreneurs like you know, are, you know, self-made first generation entrepreneurs like you are meaning? You know they formed the company, but some of them may have worked at other companies. In hindsight they realize, oh, I should have done this five years sooner, you know it. Just, it would have only been better if I'd done it five years. That's kind of. The most common answer is just, they wish they'd played it less safe. You know, they wish they'd taken, you know, more risks in college. They wish they. That's kind of the most. But that one is consistent with what most people say near the end of their life they don't regret the things they did, they regret the things they didn't do. So that tends to be the answer. But that, to me, is a really good. That's a really good answer for somebody who's pretty content with where their life is. Roank: Yeah, other than you know your wife, obviously, and I see what everybody else describes, but I feel that everything I did, I was learning something that became foundationally valuable. Dave: Yeah. Roank: You know there was a period of time I got laid off from Schnitzer in early 2009. And I didn't start up at Alter Trading until, you know, about a year later. But I did some consulting in the middle for a wonderful company, Steel Pacific Recycling in Vancouver Island, Victoria, British Columbia, and I was there for three months and it was a magical time because we were there in the wintertime. The whole family moved up. My kids were very young. We had an apartment right in Victoria. I rode a bicycle to work to the scrapyard. But I did a bunch of really interesting financial cost accounting structure set up that helped them understand their business better and those were super useful skills when I had to do a chart of accounts setup for levitated metals. We were able to slice and dice our financials. You know extremely well and I don't know if I would have used an erp system nearly as well as I do here had I not had all those little formative experience things in the end I think for me at least. I don't feel like I had a lot of wasted years throughout any of that time I learned steve jobs, as you say. Dave: Steve jobs has the saying that you can only connect the dots when you look backwards, that at the time you can't. It's not like you had some grand plan, I'm guessing you know when you left intel. It just you know. Because steve talks about. He took this calligraphy class that he audited in college and, uh, you know, and that influenced everything at apple design and fonts and and other stuff that it only makes sense looking back so that's. Roank: That's interesting. Yeah, I can. I can see that, and it is hard to connect the dots until yeah until you look back so. Dave: So here's kind of a fun one. I think you've been a like me, you're a. Well, I consider myself a naturalized texan. My wife's a native texan, so, uh, you know, if you you know. So you're also a non-native texan, but I think you've been here long enough for this question. Tex-mex or barbecue. Roank: Barbecue makes me fall asleep. I'm not saying Tex-Mex, I've always loved Tex-Mex. So yeah, we've got some great barbecue. Actually, right near the plant Rusty Buckle is some great barbecue. Near my house is Corkscrew, which just got a Michelin star, which. Dave: Oh nice. Roank: Yeah, which I still struggle to understand how that all plays out. But Texas I guess you get a star. But I love me some Lupe Torquillo yeah yeah, I am with you. Dave: Well, is there anything I didn't ask you or we didn't talk about that you wish we had or we should have? Roank: No, but I'll do you a favor and I'll plug a little bit the IC disc. I know that's not the goal of this podcast, but it is why we know each other. Yeah, so I'll tell this story if I may. Yeah, absolutely, the IC disc and levitated metals. Yeah absolutely, yeah, absolutely, disc and levitated metals. So I called you on my birthday, three months before I, a little bit before I sold the company, and I had talked to you many times previous to that about setting up an icy disc. We, like many scrap companies, are well suited to the icyDIS because the profile of our sales are high margin exports and lower margin domestic sales, and the value of, as a pass-through entity, being able to translate ordinary income into dividend income, has great benefits to the investors of a company. I think there's probably some advantages, even if you're a C-corp, but you can detail that kind of At most. I think there's probably some advantages, even if you're a C-corp, but you can detail that kind of stuff out. I don't really know. Dave: Sure. What was? Roank: interesting when we talked about it is I was in the process of selling the company and when you sell a company that's done a bunch of bonus depreciation because it built a big factory, there's always depreciation recapture that shows up as ordinary income at the time of the sale and so whatever normal ordinary income there would have been that year it was going to be much, much higher because we would have clawed back a ton of depreciation. I put a recapture on depreciation. It's ordinary income. We, like many scrap companies again, have an IC discable kind of amount of headroom of income translation from ordinary income to dividend income Well in excess of the ordinary income we normally make in any particular year, and so, like most scrap companies, there should be no reason to pay ordinary income tax. Dave: Right. Roank: Again, most scrap companies that are Nazi corpse or whatever. But in the year of the sale, all that extra headroom suddenly became valuable because I was going to have this abnormal ordinary income from the depreciation recapture, and so what would have been X million dollars of ordinary income that would have turned to dividend income wound up being something like 2.5, x, yeah, all of which I was able to use because I had so much ordinary income, yeah. And your shareholders as well. Yes, absolutely yes, I and my shareholders. And that was phenomenal. And then on top of it, I think I got to. The ICDIS lets you defer some of that dividend income into the following year. So just sat there in our bank accounts making 5% or whatever we chose to do with that money for another year more than a year, excuse me. Just truly phenomenal. The impact of the ICDIS in my space. Not an easy thing to kind of think through. You and I were just spitballing stuff. We popped it up as an option. You had to go back and think about it, but it looks like it works. And I don't know if you have done it before. Dave: No, yeah, it was just such a unique fact and it was mostly because of how new the business was. Right, if the business had been open for 10 years, we would have started the IC desk probably in year four or five it was coming, and then you would have been using it and then you would have had that transaction, the depreciation recapture, and it would have given you a bigger benefit. It would have happened anyway. It was just your circumstances were so unique is how it all fell out, and I doubt we'll ever see that. That circumstances, because it's so rare to start a business and sell it so quickly, you know I think the takeaway of it is the one. Roank: So one of the takeaways I have from this is I should have started the ICS earlier, because of the bonus depreciation as a startup of the company and the complete depreciation of the entire factory. In the first year, I and investors had a ton of NOL and net operating losses that were just going to take a while to turn into a cumulative net gain and before that happened we sold the company. I was planning on doing an IC disc in 2024, I think was my expected timeline, which is when we would have clicked over to a game and then suddenly there would have been income that I wanted to translate over into dividend income. But I really should have just done it before into dividend income but I really should have just done it before. Dave: So the question I should have asked you was if you could go back in time two years and do anything different. Give any advice to yourself. What would it have been? I mean, it's a joke, right? You would have said start the ICDISC sooner. Roank: The real advice I would have given would have been understand how your NOLs work so that you can do a donor advice fund for the ordinary income you thought you were going to. But outside of that, in truth it's a minor esoteric thing that doesn't really matter. Dave: And so, since you brought it up I rarely talk about this. Since you brought it up, just a couple quick questions. One, because the cpa firm you use actually has some icdisk expertise and you know you could have used them. So do you recall what aspect of our I remind you. Roank: Yeah, because you're, I see this guy. Okay, and the thing that I was talking about felt esoteric enough that I didn't want to click just on a cheap bastard. I didn't want to click over, you know. CPA for billable hours while they tried to figure it out and roll me in a show or something like that. That's not how I want to play now, but the truth is I just needed something done quick and fast because every day that I waited to do the icy disc was another day of revenues that I couldn't utilize. And the second reason is, you know there's a time there's time it takes to create an icy disc and set it up and all that kind of stuff. You have that down to a science and had a method to kind of quickly get me rolling on it. While you and I both know you made a bunch of money on that transaction for a couple of years of work on it, it was completely worth it to me and a very satisfying business and personal relationship that tested both of our intellectual capabilities to kind of put together and work on. I enjoyed doing it right, like when we talk about what we enjoy and work. Dave: Yeah, that was a fun thing it was, yeah, no, it was for me too, because so yeah, so few of my clients, you know, know, have that much interest, you know, getting into the weeds there, and it caused me to think of some things I hadn't thought about in this. And again, since you brought it up, in the experience, you know, the team was the responsiveness Good, I mean, was the? Is the experience been positive? Oh yeah, it's been great, yeah what about coordinating with your CPA firm, because sometimes a CPA firm who has an ICDIS practice will sometimes say things like yeah, but it'll be more seamless if it's all under one umbrella right. Umbrella right, I mean, it's the. Did you get the sense that? That it created a lot of of extra work by the cpa firm, or that balls got dropped because you didn't have one entity doing it all? Roank: I don't think I got that sense, because the cpa firm is made up of multiple people too. That, oh, it's a good point, right? I mean, it's not like the ICDISC person is the CPA that you're working with, right? Dave: You know, I hadn't thought about that, and you're right, and there's some level of communication that is required regardless. Roank: Yeah, and that. Dave: IC-DISC practice, if I recall, for that particular firm. I think it's out of a different office. Roank: Anyway, I don't think, even if they were next to each other right which are of course not next to each other because they all work remote Even if they were next to each other, still two people having to talk, and so there's still coordination that has to happen, and you know what you're talking about. In the end. There is enough esoterica on optimizing the ICDISC usage, that especially trying to maximize the ICDISC capability that I don't think others really understand and not all of them need to understand it. But what I mean by that is for many companies they can just use the stupid simple approach for doing ICDISC and it'll still let them translate all the income they have right. In my particular case, it was important to look at the transaction by transaction optimization capability of the ICDISC in order to fully utilize and maximize the amount of income I could translate to dividend income. I use shared logic as my ERP system. There is literally an ICDISC button that creates the report that you care about. Dave: Right, and so that's one of the benefits of not to interrupt you, but people ask me because, like my, our IC disc business is almost impossible to sell. In fact your CPA firm even talked to me a few years ago about buying the ICDIS practice. The problem is we're not very sellable. We have a huge, we have a concentration risk because it's all tied to one part of the tax code. So they wanted to discount that, or they would have wanted if the conversation on that far. And the second problem is I'm a craftsman, I have the primary relationship with all of the clients. So they would have made me stay around for three or five years and I'm like you know and it would have been tied to some kind of an earn out because they're going to say well, what if the IC just goes away next year? You know we want you to basically keep some of that risk. So I don't know what got me off on this tangent of that risk. Roank: So I don't know what got me off on this tangent. I hear you, and I've thought about that question on your behalf as well, because from my perspective I think your job is kind of interesting and fun. Right, you get to visit a lot of different scrap yards, talk to a bunch of different scrap dudes about a thing you're very knowledgeable about that you know really could trans dramatically improve their financial position, and yet it's still a tough sell. Right, it should be like selling. You know it's not like selling ice cream to eskimos, and yet sometimes it probably feels that way. It is that way, yeah, yeah, and also the question of how to. Because you have a couple of people, I think that work for you, right, at least? Dave: one, yeah, yeah, there's a whole team, yeah. Roank: And so, yes, if IC-DISC went away, it would be I don't know what else you guys do, but pretty close to the end of the company and that's a rough gig. And you know, the low-grade communist in me certainly is shocked, shocked by all the awesome and incredible tax code optimization tools that exist for business owners tools that exist for business owners. Dave: I mean between the IC-DISC, new market tax credits opportunity zones right Bonus appreciation just it's Cost segregation, research-. Roank: Absolutely phenomenal, right, I am now a W2 employee like a putz, you know it's just phenomenal. But if that went away then, yeah, this does die. It's a really difficult thing to try to sell, right. It's the type of thing that, I don't know, if you can't keep some level of skin in the game or risk on it. It feels like the type of thing that if you have the right person in the organization that could be the face, should be kind of employee acquired in some capacity. Dave: Well, and that opportunity exists Some of my partners, I mean I have a standing offer to basically sell my part of the business and in many ways are you familiar with the inside. Roank: I am the. Dave: There's a deep dive of tax yeah, yeah, the structure for us I've already looked at it just doesn't. It doesn't really, it's not not the right fit, but yeah, I thought this thing. You know the funny thing about the disc it's been around since 1972, but it's been quote going, going away since 1973. So I've been doing this 20 years, and I thought I might have five years before this went away or there was a change. But the key, though, is that and that's true the concentration risk is there, but on the flip side, there's also a premium. You get a specialization premium that comes along with it. It's the reason if you look at a lawyer, the more specialized they are, the higher their billing rate, and so there's a premium that comes with that specialization. I know what I was going to say, and then I doubled down further where we have a concentration of risk within the scrap metal industry. But the benefit of that, though, is that when I show up to a scrap metal conference, I'm the only one there talking about IC disc, and I'm the one that well, a scrap guy introduced us. I mean, in fact, I won't mention him by name, but I call him my best unpaid salesman. He's referred as multiple clients. For a variety of reasons, they don't use us, but he's still a big fan of uh, of the work we do. So, yeah, and then the. Finally, there's this concept that has not caught on with a lot of americans. But there's this concept of saving Like you don't have to spend all your income in any given year, so there is this concept of you can make money, put it away and then, if the business goes away, you have this thing called like a nest egg, or you know. So People should think about it, yeah, but yeah my clients, my clients who I have a relationship with, that's. Oftentimes they'll ask me hey, dave, I'm a little worried about you, like as a friend, what happens if the IC disc goes away and I'm like I'll just spend more time there? That's what will happen. Roank: If it makes you feel better, I don't worry about you. I just think it's a very interesting company sale situation. I just think it's a very interesting company sale situation. Yeah, and you know, when you look at the environment today, you could be a tweet away from getting doged. Yeah, yeah, exactly yeah. So one of the you know, keep your head down and stay quiet, kind of things which appears to be the standard business approach to today's situation. Dave: It does seem to be. Roank: Well, hey Ronak. Dave: I can't believe how fast the time has floated. This has been a blast. I really appreciate it and I hope you have a great afternoon. Thank you, it's good to talk to you. Special Guest: Ronak Shah.

Two-time Emmy and Three-time NAACP Image Award-winning, television Executive Producer Rushion McDonald interviewed Holly Cotton (breast cancer survivor, nurse, author) and Dewayne Charleston (stage 4 prostate cancer survivor). Topic: Raising awareness and eliminating disparities in Black men’s health, especially prostate cancer. 2. Holly Cotton’s Story Breast cancer survivor and nurse with a master’s degree. Author of Strong More Than Muscles. Uses her survivorship to inspire others and promote health awareness. Advocates for being a “life survivor,” not just a cancer survivor. 3. Rushion McDonald’s Personal Experience Thyroid cancer survivor since 2015. Shares how the diagnosis changed his perspective on life and purpose. Uses his platform to raise awareness and encourage proactive health decisions. 4. Dwayne’s Journey Diagnosed with stage 4 prostate cancer at age 46. All 16 biopsy samples came back positive. Told by MD Anderson urologist Dr. Lewis Sisler that only prayer could help. Fought cancer for 14 years and founded a prostate cancer awareness foundation. 5. Foundation Mission Educates Black men on prostate cancer, clinical trials, and health disparities. Addresses emotional, sexual, financial, and relational impacts of cancer. Aims to break silence and stigma around men’s health issues. 6. Breast Cancer Awareness vs. Prostate Cancer Awareness Holly explains the success of “Go Pink” campaigns for breast cancer. Dewayne and Holly aim to replicate that success with “Go Blue” for prostate cancer. Goal: Encourage men to prioritize their own health and get tested. 7. Community Impact Importance of storytelling and visibility at events like HBCU games. Emphasis on legacy, education, and proactive health care. Holly and Dewayne’s collaboration bridges gender and cancer awareness gaps. 8. Closing Rushon thanks guests for their advocacy and friendship. Encourages listeners to lead with their gifts and keep winning.

Two-time Emmy and Three-time NAACP Image Award-winning, television Executive Producer Rushion McDonald interviewed Holly Cotton (breast cancer survivor, nurse, author) and Dewayne Charleston (stage 4 prostate cancer survivor). Topic: Raising awareness and eliminating disparities in Black men’s health, especially prostate cancer. 2. Holly Cotton’s Story Breast cancer survivor and nurse with a master’s degree. Author of Strong More Than Muscles. Uses her survivorship to inspire others and promote health awareness. Advocates for being a “life survivor,” not just a cancer survivor. 3. Rushion McDonald’s Personal Experience Thyroid cancer survivor since 2015. Shares how the diagnosis changed his perspective on life and purpose. Uses his platform to raise awareness and encourage proactive health decisions. 4. Dwayne’s Journey Diagnosed with stage 4 prostate cancer at age 46. All 16 biopsy samples came back positive. Told by MD Anderson urologist Dr. Lewis Sisler that only prayer could help. Fought cancer for 14 years and founded a prostate cancer awareness foundation. 5. Foundation Mission Educates Black men on prostate cancer, clinical trials, and health disparities. Addresses emotional, sexual, financial, and relational impacts of cancer. Aims to break silence and stigma around men’s health issues. 6. Breast Cancer Awareness vs. Prostate Cancer Awareness Holly explains the success of “Go Pink” campaigns for breast cancer. Dewayne and Holly aim to replicate that success with “Go Blue” for prostate cancer. Goal: Encourage men to prioritize their own health and get tested. 7. Community Impact Importance of storytelling and visibility at events like HBCU games. Emphasis on legacy, education, and proactive health care. Holly and Dewayne’s collaboration bridges gender and cancer awareness gaps. 8. Closing Rushon thanks guests for their advocacy and friendship. Encourages listeners to lead with their gifts and keep winning.

Two-time Emmy and Three-time NAACP Image Award-winning, television Executive Producer Rushion McDonald interviewed Holly Cotton (breast cancer survivor, nurse, author) and Dewayne Charleston (stage 4 prostate cancer survivor). Topic: Raising awareness and eliminating disparities in Black men’s health, especially prostate cancer. 2. Holly Cotton’s Story Breast cancer survivor and nurse with a master’s degree. Author of Strong More Than Muscles. Uses her survivorship to inspire others and promote health awareness. Advocates for being a “life survivor,” not just a cancer survivor. 3. Rushion McDonald’s Personal Experience Thyroid cancer survivor since 2015. Shares how the diagnosis changed his perspective on life and purpose. Uses his platform to raise awareness and encourage proactive health decisions. 4. Dwayne’s Journey Diagnosed with stage 4 prostate cancer at age 46. All 16 biopsy samples came back positive. Told by MD Anderson urologist Dr. Lewis Sisler that only prayer could help. Fought cancer for 14 years and founded a prostate cancer awareness foundation. 5. Foundation Mission Educates Black men on prostate cancer, clinical trials, and health disparities. Addresses emotional, sexual, financial, and relational impacts of cancer. Aims to break silence and stigma around men’s health issues. 6. Breast Cancer Awareness vs. Prostate Cancer Awareness Holly explains the success of “Go Pink” campaigns for breast cancer. Dewayne and Holly aim to replicate that success with “Go Blue” for prostate cancer. Goal: Encourage men to prioritize their own health and get tested. 7. Community Impact Importance of storytelling and visibility at events like HBCU games. Emphasis on legacy, education, and proactive health care. Holly and Dewayne’s collaboration bridges gender and cancer awareness gaps. 8. Closing Rushon thanks guests for their advocacy and friendship. Encourages listeners to lead with their gifts and keep winning.

Dr. Joseph McCollom and Dr. Ramy Sedhom discuss precision palliative care, a new strategy that aims to align palliative care delivery with patient and caregiver needs instead of diagnosis alone. TRANSCRIPT ADN Podcast Episode 8-22 Transcript: What Is Precision Palliative Care? Rethinking a Care Delivery Problem Dr. Joseph McCollom: Hello and welcome to the ASCO Daily News Podcast. I'm your guest host, Dr. Joseph McCollom. I'm a GI medical oncologist and palliative oncologist at the Parkview Packnett Family Cancer Institute here in Fort Wayne, Indiana. So, the early benefits of palliative care for patients with cancer have been well documented, but there are challenges in terms of bandwidth to how do we provide this care, given the workforce shortages in the oncology field. So today, we'll be exploring a new opportunity known as precision palliative care, a strategy that aims to align care delivery with patient and caregiver needs and not just diagnosis alone. Joining me for this discussion is Dr. Ramy Sedhom. He is the medical director of oncology and palliative care at Penn Medicine Princeton Health and a clinical assistant professor of medicine at the University of Pennsylvania Perelman School of Medicine. Our full disclosures are available in the transcript of this episode.  Dr. Sedhom, it's great to have you on the podcast today. Thank you so much for being here. Dr. Ramy Sedhom: Thank you, Joe. It's a pleasure to be here and lucky me to be in conversation with a colleague and friend. Yes, many of us have heard about the benefits of early palliative care. Trials have shown better quality of life, reduced symptoms, and potentially even improved survival. But as we know, the reality is translating that evidence into practice, which is really, really challenging. So Joe, both you and I know that not every patient can see palliative care, or I'd even argue should see palliative care, but that also means there are still many people with real needs who still fall through the cracks. That's why I'm really excited about today's topic, which we'll be discussing, which is precision palliative care. It's a growing shift in mindset from what's this patient's diagnosis or what's this patient's prognosis, to what matters most for this person in front of me right now and what are their individual care needs. I think, Joe, it's very exciting because the field is moving from a blanket approach to one tailored to meet people where they actually are. Dr. Joseph McCollom: Absolutely, Ramy. And I think from the early days when palliative care was kind of being introduced and trying to distinguish itself, I think one of the first models that came to clinicians' eyes was Jennifer Temel's paper in The New England Journal of Medicine in 2010. And her colleagues had really looked at early palliative care integration for patients with advanced non–small cell lung cancer. And in that era – this is a pre-immunotherapy era, very early targeted therapy era – the overall prognosis for those patients are similar to the population I serve as a GI medical oncologist, pancreatic cancer today. Typically, median overall survival of a year or less. And so, a lot of her colleagues really wanted her to track overall survival alongside quality of life and depression scores as a result of that. And it really was a landmark publication because not only did it show an improvement of quality of life, but it actually showed an improvement of overall survival. And that was really, I think, revolutionary at the time. You know, a lot of folks had talked about if this was a drug, the FDA would approve it. We all in GI oncology laugh about erlotinib, which got an FDA approval for a 2-week overall survival advantage. And so, it really kind of set the stage for a lot of us in early career who had a passion in the integration of palliative care and oncology. And I think a lot of the subsequent ASCO, NCCN, COC, Commission on Cancer, guidelines followed through with that. But I think what we realized is now we're kind of sitting center stage, there's still a lot of resource issues that if we sent a referral to palliative care for every single patient diagnosed with even an advanced cancer, we would have a significant workforce shortage issue. And so, Ramy, I was wondering if you could talk a little bit about how do we help center in on who are the right patients that are going to have the greatest benefit from a palliative care specialist intervention? Dr. Ramy Sedhom: Thanks, Joe. Great question. So you mentioned Dr. Temel's landmark 2010 trial published in the New England Journal of Medicine. And it is still a game changer in our field. The results of her work showed not only improved quality of life and mood, but I think very surprisingly at the time, a survival benefit for patients with lung cancer who had received early palliative care. That work, of course, has helped shape national guidelines, as you've shared, and it also helped define early, as within 8 weeks of diagnosis. But unfortunately, there remains a disconnect. So in clinical practice, using diagnosis or stage as the only referral trigger doesn't really match the needs that we see show up. And I think unfortunately, the other part is that approach creates a supply demand mismatch. We end up either referring more patients than palliative care teams can handle, or at the opposite extreme, we end up referring no one at all. So, I actually just wanted to quickly give, for example, two real world contrasts. So one center that I actually have friends who work in, tried as a very good quality improvement incentive, auto-refer all patients with stage IV pancreas cancer to palliative care teams. And while very well intentioned, they saw very quickly that in a two-month period, they had 30 new referrals. And on the palliative care side, there were only 15 available new patient slots. On the other hand, something that I often see in practice, is a situation where, for example, consider the case of a 90-year-old with a low-grade B-cell lymphoma. On paper, low-risk disease, but unfortunately, when you look under the microscope, this gentleman is isolated, has symptoms from his bulky adenopathy, and feels very overwhelmed by many competing illnesses. This is someone who, of course, may benefit from palliative care, but probably doesn't check the box. And I think this is where the model of precision palliative care steps in. It's not really about when was someone diagnosed or what is the prognosis or time-based criteria of their cancer, but it's really fundamentally asking the question of who needs help, what kind of help do they need, and how urgently do we need to provide this help? And I think precision palliative care really mirrors the logic and the philosophy of precision oncology. So just like we've made strides trying to match therapies to tumor biology, we also need to have the same attention and the same precision to match support to symptoms, to context of a patient situation and their caregiver, and also to their personal goals. So I think instead of a blanket referral, we really need to tailor care, the right support at the right moment for the right person to the right care teams. And I think to be more precise, there's really four core elements to allow us to do this well. So first, we really need to implement systematic screening. Let's use what we already have. Many of our centers have patient reported outcomes. The Commission on Cancer motivates us to use distress screening tools. And the EHR is there, but we do very little to flag and to surface unmet care needs. We have seen amazing work from people like Dr. Ethan Bash, who is the pioneer on patient-reported outcomes, and Dr. Ravi Parikh, who used to be my colleague at Penn, now at Emory, who show that you could use structured data and machine learning to identify some of these patient needs in real time. The second piece is after a systematic screening, we really need to build very clear referral pathways. One very good example is what the supportive care team at MD Anderson has done, of course, led by Dr. Eduardo Brera and Dr. David Huey, where they have, for example, designed condition-specific triggers. Urgent referrals, for example, to palliative care for severe symptoms, where they talk about it like a rapid response team. They will see them within 72 hours of the flag. But at the same time, if the unmet need is a caregiver distress, perhaps the social work referral is the first part of the palliative care intervention that needs to be placed. And I think this helps create both clarity and consistency but also it pays attention to that provider and availability demand mismatch. Third, I really think we need to triage smartly. As mentioned in the prior example, not every patient needs every team member of the palliative care team. Some benefit most from the behavioral health intervention. Others might benefit from chaplaincy or the clinician for symptom management. And I think aligning intensity with complexity helps us use our teams wisely. Unfortunately, the greatest barrier in all of our health care systems is time and time availability. And I think this is one strategic approach that I have not yet seen used very wisely. And fourth, I really think we need to embrace interdisciplinary care and change our healthcare systems to focus more on value. So this isn't about more consults or RVUs. I think it's really about leveraging our team strengths. Palliative care teams or supportive care teams usually are multidisciplinary in their core. They often have psychologists, social workers, sometimes they have nurse navigators. And I think all of these are really part of that engine of whole person care. But unfortunately, we still are not set up in care delivery systems that unfortunately to this day still model fee for service where the clinician or the physician visit is the only quote unquote real value add. Hopefully as our healthcare systems focus more on delivery and on value, this might help really embrace the structure to bring through the precision palliative care approach. Dr. Joseph McCollom: No, I love those points. You know, we talk frequently in the interdisciplinary team about how a social worker can spend 5 minutes doing something that I could not as a physician spend an hour doing. But does every patient need every member every time? And how do we work as a unified body to deliver that dose of palliative care, specialized palliative care to those right patients and match them? And I think that perfect analogy is in oncology as a medical oncologist, frequently I'm running complex next-generation sequencing paneling on patients' tumors, trying to find out is there a genetic weakness? Is there a susceptibility to a targeted therapy or an immunotherapy so that I can match and do that precision oncology, right patient to the right drug? Similarly, we need to continue to analyze and find these innovative ways like you've talked about, PROs, EHR flags, machine learning tools, to find those right patients and match them to the right palliative care interdisciplinary team members for them. I know we both get to work in oncology spaces and palliative and supportive spaces in our clinical practice. Share a little bit, if you could, Ramy, about what that looks like for your practice. How do you find those right patients? And how do you then intervene with that right palliative oncology dose? Dr. Ramy Sedhom: So Joe, when I first started in this space as a junior faculty, one thing became immediately clear. I think if we rely solely on physicians to identify the patients for palliative care, we're unfortunately going to be very limited by what we individually, personally observe. And I think that's what reflects the reality that many patients have real needs that go unseen. So over the past few years, I've really worked with a lot of my colleagues to really work the health system to change that. The greatest partnership I've personally had has been working with our informatics team to build a real time EHR integrated dashboard that I think helps us give us a broader view of patient needs. What we really think of as the population health perspective. Our dashboard at Penn, for example, pulls in structured data like geriatric assessment results, PHQ-4 screens, patient reported outcomes, whether or not they've been hospitalized, whether or not these hospitalizations are frequent and recurrent. And I think it's allowed us to really move from a reactive approach to one that's more proactive. So let me give you a practical example. So we have embedded in our cancer care team, psycho-oncologists. They share the same clinic space, they're right down the hall. And we actually use this shared dashboard to review weekly trends in distress scores and patient reported outcomes. And oftentimes, if they see a spike in anxiety or worsening symptoms like depression, they'll reach out to me and say, “Hey, I noticed Mrs. Smith reported feeling very anxious today. Do you think it'd be helpful if I joined you for her visit?” And I think that's how we could really use data and teamwork to offer and maximize the right support at the right time. Like many of our other healthcare systems, we also have real-time alerts for hospitalizations. And I think like Dr. Temel's most recent trial, which we'll discuss at some point, I'm sure, it's another key trigger for vulnerability. I think whenever someone's admitted or discharged, we try to coordinate with our palliative care colleagues to assess do they need follow-up and in what timeline. And we know that these are common triggers, progression of disease, hospitalizations, drops in quality-of-life. And it's actually surprisingly simple to implement once you set up the right care structures. And I think these systems don't just help patients, which is what I quickly learned. They also help us as clinicians too. Before we expanded our team, I often felt this weight, especially as someone dual trained in oncology and palliative medicine, as trying to be everything to everyone. I remember one patient in particular, a young woman with metastatic breast cancer who was scheduled for a routine pre-chemo visit with me. Unfortunately, on that day, she had a very dramatic change in function. We whisked her down to x-ray and it revealed a pretty large pathologic fracture in her femur. And suddenly what was scheduled as a 30-minute visit became a very complex conversation around prognosis, urgent need for surgery and many, many life changes. And when I looked at my Epic list, I had a full waiting room. And thankfully, because we have embedded palliative care in our team, I was able to bring in Dr. Collins, the physician who I work with closely, immediately. She spent the full hour with the patient while I was able to continue seeing other patients that morning. And I think that's what team-based care makes possible. It's not just more hands on deck but really optimizing the support the patient needs on each individual day. And I think last, we're also learning a lot from behavioral science. So many institutions like Penn, Stanford, Massachusetts General, they've experimented with a lot of really interesting prompts in the EHR. One of them, for example, is the concept of nodes or the concept of prompt questions. Like, do you think this patient would benefit from a supportive care referral? And I think these low-level nudges, in a sense, can actually really dramatically increase the uptake of palliative care because it makes what's relevant immediately salient and visible to the practicing physician. So I think the key, if I had to maybe finish off with a simple message: It's not flashy tech, it's not massive change against staffing, but it's having a local champion and it's working smarter. It's asking the questions of how can we do this better and setting up the systems to make them more sustainable. Dr. Joseph McCollom: I appreciate you talking about this because I think a lot of folks want to put the wheels on in some way and they don't know where to get started. And so I think some of the models that you've been able to create, being able to track patients, screen your population, find the right individuals, and then work within that team to be able to extend, I think when you have an embedded palliative care specialist in your clinic, they expand your practice as a medical oncologist. And so you can make that warm handoff. And that patient and that caregiver, when they view the experience, they don't view you as a medical oncologist, someone else as a palliative care specialist, they view that team approach. And they said, "The team, my cancer team took care of me." And I think we can really harness a lot of the innovative technological advancements in our EHR to be able to prompt us in this work. I know that Dr. Temel had kind of set the stage for early palliative care intervention, and you did mention her stepped palliative care trial. Where do you see some of the future opportunities as we continue to push the needle forward as oncologists and palliative care specialists? What do you see as being the next step? Dr. Ramy Sedhom: So for those who are not familiar with the stepped palliative care trial, again, work by Dr. Temel, I think it's really important to explain not just the study itself, but I think more importantly, what it's representing for the future of our field. First, I really want to acknowledge Dr. Temel, who is a trailblazer in palliative oncology. Her work has not only shaped how we think about timing and delivery, but really about the value of supportive care. And more importantly, I think for all the young trainees listening, she had shown that rigorous randomized trials in palliative care are possible and meaningful. And I think for me, one quick learning point is that you could be an oncologist and lead this impactful research. And she's inspired many and many of us. Now let's quickly transition to her study. So in this trial, the stepped palliative care trial, patients with advanced lung cancer were randomized into two groups. One group followed the model from her landmark 2010 New England Journal of Medicine paper, which was structured monthly palliative care visits, again, within eight weeks of diagnosis. The second group, which is in this study, the intervention or the stepped palliative care group, received a single early palliative care visit. Think of this as a meet and greet. And then care was actually stepped up. If one of three clinical triggers happened. One, a decline in patient reported quality of life as measured by PROs. Two, disease progression, or three, hospitalization. And the findings which were presented at ASCO 2024 were striking. Clinical outcomes, very similar between the two groups. And this included quality-of-life, end-of-life communication, and resource use. But I think the take-home point is that the number of palliative care visits in the stepped group was significantly lower. So in other words, same impact and fewer visits. This was a very elegant example of how we can model precision palliative care, right sizing patient care based on patient need. So where do we go from here? I think if we want this model to take root nationally, we really need to pull on three key levers: healthcare systems, healthcare payment, and healthcare culture. So from a system alignment, unfortunately, as mentioned too often, the solution to gaps in palliative care is we need more clinicians. And while yes, that's partly true, it's actually not the full picture. I think what we first need to do and what's more likely to be achieved is to develop systems that focus on building the infrastructure that maximizes the reach of our existing care teams. So this means investing in nurse navigation, real-time dashboards with patient-reported outcomes and EHR flags, and again, matching triage protocols where intensity matches complexity. And the goal, as mentioned, isn't to maximize consults, but to really maximize deployment of expertise based on need. The second piece is, of course, we need payment reform. So the stepped palliative care model only works when it allows continuous patient engagement. But unfortunately, current pay models don't reward or incentivize that. In fact, electronic PROs require a very high upfront financial investment and ongoing clinician time with little to no reimbursement. Imagine if we offered bundled payments or value-based incentives for teams that integrated PROs. Or imagine if we reimbursed palliative care based on impact or infrastructure instead of just fee-for-service volume. There is a lot of clear evidence that tele-palliative care is effective. In fact, it was the Plenary at ASCO 2024. Yet we're still battling these conversations around inconsistent reimbursement, and we're always waiting on whether or not telehealth waivers are gonna continue. So I think most importantly is we really need to recognize the broader scope of what palliative care offers, which is caregiver support, improving navigation, coordinating very complex transitions. To me, and what I've always prioritized as a champion at Penn, is that palliative care is not a nice to have, and neither are all of these infrastructures, but they're really essential to whole person care, and they need to be financially supported. And last, we really need a culture shift. We need to change from how palliative care is perceived, and it can't be something other. It can't be something outside of oncology, but it really needs to be embraced as this is part of cancer care itself. I often see hesitancy from many oncologists about introducing palliative care early. But it doesn't need to be a dramatic shift. I think small changes in language, how we introduce the palliative care team, and co-management models can really go a very long way in normalizing this part of patient care. And I'm particularly encouraged, Joe, by one particular innovation in this space, which is really the growth of many startups. And one startup, for example, is Thyme Care, where I've seen them working with many, many private practices across the country, alongside partnerships with payers to really build tech-enabled navigation that tries to basically maximize triage support with electronic PROs. And to me, I really think these models can help scale access without overwhelming current care teams. So precision palliative care, Joe, in summary, I think should be flexible, scalable, and really needs to align based on what patients need. Dr. Joseph McCollom: No, I really appreciate, Ramy, you talking about that it really takes a village to get oncology care in both a competent and a compassionate way. And we need buy-in champions at all levels: the system level, the administrative level, the policy level, the tech level. And we need to change culture. I kind of want to just get your final impressions and also make sure that we make our listeners aware of our article. We should be able to have this in the show notes here as well to find additional tools and resources, all the studies that were discussed in today's episode. But, Ramy, what are some of your kind of final takeaways and conclusions? Dr. Ramy Sedhom: Before we wrap up, I just want to make sure we highlight a very exciting opportunity for residents considering a future in oncology and palliative medicine. Thanks to the leadership of Dr. Jamie Von Roen, who truly championed this cause, ASCO and the ABIM (American Board of Internal Medicine) have partnered to create the first truly integrated palliative care oncology fellowship. Trainees can now double board in just two years or triple board in three with palliative care, oncology, and hematology. And I think, Joe, as you and I both know, it's incredibly rewarding and meaningful to work at this intersection. To close our message, if there's one message I think listeners should carry with them, it's that palliative care is about helping people live as well as possible for as long as possible. And precision palliative care simply helps us do that better. We need to really develop systems that tailor support to individual need, value, and individual goals. Just like our colleagues in precision oncology mentioned, getting the right care to the right patient at the right time, and I would add in the right way. For those who want to learn more, I encourage you to read our full article in JCO, which is “Precision Palliative Care As a Pragmatic Solution for a Care Delivery Problem.” Joe, thank you so, so much for this thoughtful conversation and for your leadership in our field. And thank you to everyone for listening. Thank you all for being champions of this essential part of cancer care. If you haven't yet joined the ASCO Palliative Care Communities of Practice, membership is free, and we'd love to have you. Dr. Joseph McCollom: Thank you, Ramy, not only for sharing your insights today, but the pioneering work that you have done in our field. You are truly an inspiration to me in clinical practice, and it is an honor to call you both a colleague and friend.  And thank you for our listeners for joining us today. If you value the insights that you've heard on the ASCO Daily News Podcast, please subscribe, rate, and review wherever you get your podcasts. Thanks again. Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Follow today's speakers:   Dr. Joseph McCollom @realbowtiedoc Dr. Ramy Sedhom @ramsedhom Follow ASCO on social media:   @ASCO on X (formerly Twitter) ASCO on Bluesky  ASCO on Facebook   ASCO on LinkedIn   Disclaimer: Dr. Joseph McCollom: No relationships to disclose Dr. Ramy Sedhom: No relationships to disclose

Cancer, Character, and Calling: The Oncologist's Journey, hosted by Girindra Raval, MD, is a podcast highlighting how top oncologists have navigated the field over the course of their careers, the passion that drove them to enter the oncology space, and the ongoing work that will continue to transform cancer care. Each episode, Raval will welcome a top oncologist to dive into their background, highlight their career achievements, discuss key issues still being addressed in their fields, and explore their interests outside of the clinic and lab. In this episode, Raval welcomed Jorge Cortes, MD, who is director of the Georgia Cancer Center and a professor in the Department of Medicine at Augusta University. Raval is an associate professor in the Department of Medicine: Hematology and Oncology at the Medical College of Georgia of Augusta University. In their conversation, Raval and Cortes dived into Cortes' upbringing in Mexico, his family life, and his experience earning his medical degree from the Universidad Nacional Autonoma de Mexico in Mexico City. They also spoke about Cortes' work during his 27-year tenure at The University of Texas MD Anderson Cancer Center in Houston, where he served as a professor of medicine, deputy department chair, chair of the acute myeloid leukemia and chronic myeloid leukemia sections, and deputy division chair, among other roles. Cortes detailed how that experience facilitated long-lasting collaborations and friendships. He then touched on his goals as director of the Georgia Cancer Center since taking over the role in 2019 and explained how it felt to leave MD Anderson after nearly 3 decades. Raval and Cortes also discussed how the hematologic oncology field has evolved during Cortes' career and how he expects the management of these malignancies as ongoing research continues. Cortes also highlighted his goals as director of the Georgia Cancer Center. 

This episode features a fascinating conversation with Dr. Kendall Stewart, a pioneer in integrating functional medicine, genetics, and neurology. Dr. Stewart shares his journey from traditional ear, nose, and throat surgery to championing holistic patient care, where nutrition, preparation, and cellular health take center stage in both surgical outcomes and chronic disease management.Key Topics:Functional Medicine Before It Was Trendy:Dr. Stewart reveals his early adoption of biochemistry, nutrition, and immune system support—long before "functional medicine" became a buzzword.Surgery, Preparation, and Recovery:Discover why how you prepare for surgery (and your post-op care) radically affects recovery—and how insurance companies once overlooked the impact of nutrition.Biochemistry, Virology, and Immune System Health:Learn how Dr. Stewart's research background at MD Anderson led him to understand the critical role of boosting the body's immune system, especially in viral illnesses.Integrative Patient Care:From autism to Alzheimer's and chronic sinus issues, Dr. Stewart explains why a whole-body, systems-based approach is crucial for true healing.Nutrigenomics & Genetics in Health:Practical, easy-to-understand insights into nutrigenomics, pharmacogenetics, and how single nucleotide polymorphisms (SNPs) shape our nutritional and medication needs.Inflammation and Chronic Illness:Explore how inflammation connects the immune and nervous systems—and why controlling it can be the KEY to managing everything from anxiety and POTS to migraines and long COVID.Peptides, Mitochondria, and Advanced Recovery:Real-world clinical examples of peptides, exosomes, and nutritional strategies used for surgical recovery, chronic neurological conditions, and inflammation—plus Dr. Stewart's personal recovery journey after knee replacement.What Mainstream Medicine Misses:Why compartmentalizing organ systems fails patients, and how personalized, genetics-driven approaches are reshaping the future of medicine.Prevention and Longevity:The importance of early genetic screening, metabolic testing, and how functional medicine is paving the way for healthier, longer lives.Notable Quotes:"People come to get well—they don't care what you call it, they care how you're going to help them get out of this.""You can't separate the immune system from the nervous system. Inflammation can change you in 10 minutes, chemicals cannot.""Functional medicine is just understanding biochemistry and physiology down to the details—most doctors just forgot."Resources & Links:Follow Dr. Kendall Stewart on Instagram: @coffeewithdrstewartDr. Stewart's Podcast: Coffee with Dr. Stewart Neurobiologics Supplements: neurobiologics.com Connect with the Show:Subscribe to Health, Wealth and The Ultimate Self on all your major podcast streaming platformsFollow us on Instagram @healthwealthultimateself and www.youtube.com/@healthwealthandtheultimate2269Leave a review or share your thoughts—your feedback keeps us growing!If you want to dive deeper into functional medicine, nutrigenomics, or recovery strategies, this episode is a must-listen.#Podcast#HealthPodcast#FunctionalMedicinePodcast#WellnessPodcast#IntegrativeMedicine#BiohackingPodcast#HealthTalk#DoctorPodcast#FunctionalMedicine#Nutrigenomics#GeneticTesting#Epigenetics#PersonalizedMedicine#PrecisionMedicine#SNPs#Pharmacogenomics#BiohackingYours in Health,The Health, Wealth and Ultimate Self Team!

Join the Behind the Knife Surgical Oncology Team as we discuss the two key studies investigating optimal management strategies of neuroendocrine tumors of the small bowel. Hosts: - Timothy Vreeland, MD, FACS (@vreelant) is an Assistant Professor of Surgery at the Uniformed Services University of the Health Sciences and Surgical Oncologist at Brooke Army Medical Center - Daniel Nelson, DO, FACS (@usarmydoc24) is Surgical Oncologist/HPB surgeon at Kaiser LAMC in Los Angeles. - Connor Chick, MD (@connor_chick) is a 2nd Year Surgical Oncology fellow at Ohio State University. - Lexy (Alexandra) Adams, MD, MPH (@lexyadams16) is a 1st Year Surgical Oncology fellow at MD Anderson. - Beth (Elizabeth) Barbera, MD (@elizcarpenter16) is a PGY-6 General Surgery resident at Brooke Army Medical Center Learning Objectives: In this episode we review two important papers that discuss optimal management strategies of neuroendocrine tumors (NET) of the small bowel.  The first paper by Singh and colleagues discusses the NETTER-2 trial investigating the role of radioligand therapy for NET as a first-line treatment.  The second article by Maxwell et all challenges surgical dogma regarding optimal debulking cutoffs for debulking of NET. Links to Papers Referenced in this Episode: 1.     Singh S, Halperin D, Myrehaug S, Herrmann K, Pavel M, Kunz PL, Chasen B, Tafuto S, Lastoria S, Capdevila J, García-Burillo A, Oh DY, Yoo C, Halfdanarson TR, Falk S, Folitar I, Zhang Y, Aimone P, de Herder WW, Ferone D; all the NETTER-2 Trial Investigators. [177Lu]Lu-DOTA-TATE plus long-acting octreotide versus high‑dose long-acting octreotide for the treatment of newly diagnosed, advanced grade 2-3, well-differentiated, gastroenteropancreatic neuroendocrine tumours (NETTER-2): an open-label, randomised, phase 3 study. Lancet. 2024 Jun 29;403(10446):2807-2817. doi: 10.1016/S0140-6736(24)00701-3. Epub 2024 Jun 5. PMID: 38851203. https://pubmed.ncbi.nlm.nih.gov/38851203/ 2.     Maxwell JE, Sherman SK, O'Dorisio TM, Bellizzi AM, Howe JR. Liver-directed surgery of neuroendocrine metastases: What is the optimal strategy? Surgery. 2016 Jan;159(1):320-33. doi: 10.1016/j.surg.2015.05.040. Epub 2015 Oct 9. PMID: 26454679; PMCID: PMC4688152. https://pubmed.ncbi.nlm.nih.gov/26454679/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

Abby Trahan is the Associate Director of Philanthropy at MD Anderson Cancer Center and one of two recipients of the 2025 Outstanding Young Professional award from the Association of Fundraising Professionals. In just five years, Abby has delivered transformational fundraising results—from growing monthly giving at the Houston Food Bank to securing major gifts and endowed support at the University of Houston Law Center. Now at MD Anderson, she brings her passion for equity, mentorship, and community-driven impact to one of the nation's leading cancer centers. We spoke with her live at ICON, the association's international conference in Seattle, Washington.

Broadcast from KSQD, Santa Cruz on 6-12-2025: Dr. Dawn opens with alarming news about NIH budget cuts devastating cancer research just as breakthrough CAR-T cell therapy shows promise for gastrointestinal cancers. This personalized immunotherapy extracts patients' T cells, engineers them to target specific cancer antigens, and makes them essentially immortal before reinfusion. While previously successful only for blood cancers like leukemia and lymphoma, researchers achieved tumor shrinkage in 25% of solid GI tumor patients. However, devastating layoffs forced removal of two patients from trials due to staff shortages and supply chain disruptions. Dr. Dawn emphasizes how pregnancy can worsen hidden cancers due to immune suppression, explaining why aggressive metastasized cancers often appear shortly after childbirth. Dr. Dawn takes a call from Bob about concerning forehead growths his dermatologist examined. She speculates they're likely seborrheic keratoses - benign, stuck-on appearing growths common in sun-exposed areas that look like crumpled brown paper "spit-wads". These aging-related changes are harmless and can even be picked off, though she warns against repeatedly traumatizing any skin area as this increases cancer risk through accumulated DNA damage. She explains how repetitive trauma in occupational settings creates statistically higher cancer risks, comparing it to filling a bingo card of cellular errors. She addresses an email about Joe Tippens' cancer cure protocol involving fenbendazole, an anti-parasitic drug. Dr. Dawn explains this viral social media phenomenon began when Tippens claimed his lung cancer was cured by fenbendazole, but he was simultaneously receiving Keytruda immunotherapy at MD Anderson. The story spread rapidly in South Korea, causing pharmacy shortages. Unvalidated internet health information can spread dangerously. Dr. Dawn compares it to old-fashioned medicine show scams. trend Dr. Dawn warns about a recent vitamin B6 toxicity misdiagnosis trend affecting her patients who were told they had dangerous levels of B6 despite lacking neuropathy symptoms. Accuracy requires fasting 12 hours before blood draws, otherwise creating false elevations from recent vitamin consumption. More critically, she alerts listeners about biotin(Vitamin B7) interference with laboratory tests using biotin-streptavidin techniques. High-dose biotin supplements are often used in hair and nail health growth formulas. This can falsely alter tests for thyroid hormones, vitamin D, sex hormones, cortisol and dangerously, troponin levels that diagnose heart attacks. This could lead to missed myocardial infarctions in emergency rooms, potentially causing fatal outcomes. Dr. Dawn takes a call from Richard seeking information about a previous radio program guest. She guides him to use on-line resources at ksqd.org to find program details, pivoting into praise for libraries as community centers offering far more than internet access. She emphasizes libraries provide serendipitous discovery that algorithms can't match, encouraging people to explore their local library systems for events, historical collections, and personal assistance from knowledgeable librarians eager to help visitors navigate both physical and digital resources. She discusses the concerning trend of giving melatonin to children, calling it "the Grinch that stole children's bedtime." While used prescription-only for severe developmental disorders in Denmark and EU countries, American children receive melatonin gummies regularly, with one in five preteens using it occasionally. Dr. Dawn explains melatonin is a hormone affecting pancreas, heart, fat tissue, and reproductive organs still developing in children. Supplemental doses create blood levels 10 times higher than natural peaks, representing an uncontrolled medical experiment on developing brains and bodies. Poison control calls for melatonin ingestion increased 530% between 2012-2021, with one tragic case involving a three-month-old death where 20 melatonin bottles were found in the home. Dr. Dawn concludes by debunking food expiration date myths, explaining that Americans waste a third of food ($7 billion annually) due to misunderstanding labels. Most shelf-stable foods simply degrade in quality rather than becoming dangerous after printed dates. She notes acidic dairy products like yogurt resist bacterial contamination due to protective bacteria,and even surface mold can be scraped off safely. However, she emphasizes trusting expiration dates on lunch meats and deli products, which pose real listeria risks when stored improperly. California will soon simplify labeling laws to reduce confusion between quality and safety dates.

Broadcast from KSQD, Santa Cruz on 6-12-2025: Dr. Dawn opens with alarming news about NIH budget cuts devastating cancer research just as breakthrough CAR-T cell therapy shows promise for gastrointestinal cancers. This personalized immunotherapy extracts patients' T cells, engineers them to target specific cancer antigens, and makes them essentially immortal before reinfusion. While previously successful only for blood cancers like leukemia and lymphoma, researchers achieved tumor shrinkage in 25% of solid GI tumor patients. However, devastating layoffs forced removal of two patients from trials due to staff shortages and supply chain disruptions. Dr. Dawn emphasizes how pregnancy can worsen hidden cancers due to immune suppression, explaining why aggressive metastasized cancers often appear shortly after childbirth. Dr. Dawn takes a call from Bob about concerning forehead growths his dermatologist examined. She speculates they're likely seborrheic keratoses - benign, stuck-on appearing growths common in sun-exposed areas that look like crumpled brown paper "spit-wads". These aging-related changes are harmless and can even be picked off, though she warns against repeatedly traumatizing any skin area as this increases cancer risk through accumulated DNA damage. She explains how repetitive trauma in occupational settings creates statistically higher cancer risks, comparing it to filling a bingo card of cellular errors. She addresses an email about Joe Tippens' cancer cure protocol involving fenbendazole, an anti-parasitic drug. Dr. Dawn explains this viral social media phenomenon began when Tippens claimed his lung cancer was cured by fenbendazole, but he was simultaneously receiving Keytruda immunotherapy at MD Anderson. The story spread rapidly in South Korea, causing pharmacy shortages. Unvalidated internet health information can spread dangerously. Dr. Dawn compares it to old-fashioned medicine show scams. trend Dr. Dawn warns about a recent vitamin B6 toxicity misdiagnosis trend affecting her patients who were told they had dangerous levels of B6 despite lacking neuropathy symptoms. Accuracy requires fasting 12 hours before blood draws, otherwise creating false elevations from recent vitamin consumption. More critically, she alerts listeners about biotin(Vitamin B7) interference with laboratory tests using biotin-streptavidin techniques. High-dose biotin supplements are often used in hair and nail health growth formulas. This can falsely alter tests for thyroid hormones, vitamin D, sex hormones, cortisol and dangerously, troponin levels that diagnose heart attacks. This could lead to missed myocardial infarctions in emergency rooms, potentially causing fatal outcomes. Dr. Dawn takes a call from Richard seeking information about a previous radio program guest. She guides him to use on-line resources at ksqd.org to find program details, pivoting into praise for libraries as community centers offering far more than internet access. She emphasizes libraries provide serendipitous discovery that algorithms can't match, encouraging people to explore their local library systems for events, historical collections, and personal assistance from knowledgeable librarians eager to help visitors navigate both physical and digital resources. She discusses the concerning trend of giving melatonin to children, calling it "the Grinch that stole children's bedtime." While used prescription-only for severe developmental disorders in Denmark and EU countries, American children receive melatonin gummies regularly, with one in five preteens using it occasionally. Dr. Dawn explains melatonin is a hormone affecting pancreas, heart, fat tissue, and reproductive organs still developing in children. Supplemental doses create blood levels 10 times higher than natural peaks, representing an uncontrolled medical experiment on developing brains and bodies. Poison control calls for melatonin ingestion increased 530% between 2012-2021, with one tragic case involving a three-month-old death where 20 melatonin bottles were found in the home. Dr. Dawn concludes by debunking food expiration date myths, explaining that Americans waste a third of food ($7 billion annually) due to misunderstanding labels. Most shelf-stable foods simply degrade in quality rather than becoming dangerous after printed dates. She notes acidic dairy products like yogurt resist bacterial contamination due to protective bacteria,and even surface mold can be scraped off safely. However, she emphasizes trusting expiration dates on lunch meats and deli products, which pose real listeria risks when stored improperly. California will soon simplify labeling laws to reduce confusion between quality and safety dates.

RUSH MD Anderson Cancer Center's team of medical oncologists, thoracic surgeons and radiation oncologists works collaboratively to provide patients with advanced, comprehensive care for non-small cell lung cancer. In this episode of Rounding at Rush, thoracic surgeon Nicole Geissen, DO, medical oncologist Koosha Paydary, MD, and radiation oncologist Gaurav Marwaha, MD, discuss their and other RUSH MD Anderson clinicians' efforts diagnosing and treating non-small cell lung cancer. In particular, they talk about RUSH MD Anderson's novel lung cancer screening program, as well as innovative new therapies RUSH MD Anderson clinicians are using to improve patient outcomes.

On Thursday's show: We learn about a $150 million donation that will create the Kinder Children's Cancer Center, a new initiative to fight childhood cancer at MD Anderson Cancer Center and Texas Children's Hospital. The gift is one of the largest such donations in the history of the Texas Medical Center and one of the largest ever given to a pediatric hospital in the country.Also this hour: Comedian Ramy Youssef performs Friday night at House of Blues, and he has a new animated series on Amazon Prime called #1 Happy Family USA! We revisit a 2019 conversation with him about how he got into comedy and about how much of his standup material and work on television has revolved around the experience of growing up Muslim in America.Then, a Houston mother lost her parental rights to her children for life because of allegations her ex-husband made in court. We learn why the Texas Supreme Court unanimously overturned that ruling and what it means for how protective orders are issued here.And Laura Walker visits a farm run by the Socialites Riding Network, a Black-owned nonprofit that teaches sustainable agriculture and an appreciation for animals.

Highly skilled clinicians at RUSH MD Anderson Cancer Center diagnose, treat and prevent all types of skin cancer and other skin conditions. One treatment tool at their disposal is Mohs micrographic surgery, an advanced, minimally invasive and highly effective treatment for skin cancer. In this podcast, Miriam Mafee, MD, the division chief of Dermatological Surgery at Rush University Medical Center and a Mohs micrographic surgeon at RUSH MD Anderson, discusses how and when to use Mohs surgery, its advantages, as well as how this type of surgery continues to evolve. “We use appropriate use criteria (AUC), which helps separate less severe from more severe cases of skin cancer. This helps to maximize the utilization of Mohs surgery. We don't use Mohs surgery for every single skin cancer patient or every single skin cancer case. There are times where it really makes sense to be used and times where it doesn't. AUC, which you can find on an app, is a great help with this.”

"Microbiome" is a buzzword these days--but many people don't know what it means. As we re-assess the lasting impact diet may have on our health, researchers are examining the role of gut health as possible causes for the dramatic uptick in colorectal cancer in young people. Katie Couric, founder of Katie Couric Media and Stand Up To Cancer, hosts an expert-led panel including Dr. Nancy You, a surgeon and director of the Young-Onset Colorectal Cancer Program at MD Anderson, Dr. Susan Bullman–an Associate Professor of Gastrointestinal Medical Oncology at The University of Texas MD Anderson Cancer Center, and Julie Smolyansky, CEO of Lifeway Foods, to discuss the impact of diet on the gut microbiome.See omnystudio.com/listener for privacy information.

It's Friday so we're breaking down the biggest stories in Houston. Host Raheel Ramzanali and Pulitzer Prize finalist Evan Mintz talk about how a big drop in oil prices could threaten our economy, the latest fight between the city of Houston and Harris County, and the latest scam you need to watch out for! Dive deeper into the stories we talked about on today's show:  Officials urge Houston drivers to watch out for scam parking tickets Baylor College of Medicine lays off 122 employees as Trump funding cuts loom MD Anderson cuts spending, pauses some hiring after multi-million dollar budget shortfall A third of eligible Houston employees accept buyout package, saving city $11M this fiscal year Texas Senate passes bill to limit Harris County's authority over millions of surplus toll road funds Houston-Galveston Area Council studying light rail, bus route feasibility in Fort Bend County Third-Party Permitting Bill & Bill for Stairway Requirements  How Houston became one of America's biggest Vietnamese hubs, 50 years after the fall of Saigon If you enjoyed today's interview with Stages Houston, Denise Fennell, learn more here. Learn more about the sponsors of this May 2nd episode: Aura Frames - Get $35-off plus free shipping on the Carver Mat frame with Promo Code CITYCAST Visit Port Aransas Downtown Houston+ Looking for more Houston news? Then sign up for our morning newsletter Hey Houston  Follow us on Instagram  @CityCastHouston Don't have social media? Then leave us a voicemail or text us at +1 713-489-6972 with your thoughts! Have feedback or a show idea? Let us know!  Interested in advertising with City Cast? Let's Talk! Photo: Jason Fochtman/Houston Chronicle via Getty Images Learn more about your ad choices. Visit megaphone.fm/adchoices

Dr. Jenny Underwood, a board-certified OB-GYN from Texas has been navigating the world of locum tenens and telehealth since 2019. Dr. Underwood shares her unique journey from fellowship training at MD Anderson to embracing locum tenens work, which has allowed her to maintain her clinical skills while achieving a strong work-life balance.Dr. Underwood discusses the challenges of balancing her professional responsibilities with raising three children, and how locum tenens has provided the flexibility she needed. She highlights the importance of choosing assignments based on schedule rather than location, and the support she received from locum agencies in obtaining state licenses.Interested in locum tenens? Check out Weatherby Healthcare (weatherbyhealthcare.com).

Welcome to another episode of the Oncology Brothers podcast! In this episode, Drs. Rohit and Rahul Gosain, both practicing community medical oncologists, continue their discussion on HER2-positive biliary tract cancer. They are joined by Dr. Shubham Pant from MD Anderson, who shares his expertise on this rapidly evolving field. In this episode, we cover: •⁠  ⁠The importance of HER2 testing in biliary tract cancers, including intrahepatic and extrahepatic cholangiocarcinomas and gallbladder cancers. •⁠  ⁠Who should be tested for HER2 positivity and how to classify HER2-positive disease. •⁠  ⁠The role of next-generation sequencing (NGS) and immunohistochemistry (IHC) in determining HER2 status. •⁠  ⁠Current treatment options for HER2-positive biliary tract cancer, including the latest clinical trials and approved therapies like trastuzumab deruxtecan and zanidatamab. •⁠  ⁠The significance of patient-centered decision-making and managing side effects associated with these treatments. •⁠  ⁠Insights into the potential for brain metastases in biliary tract cancer and the importance of ongoing surveillance. Join us as we delve into the latest data and strategies for managing HER2-positive biliary tract cancer, and stay tuned for our next episode where we will discuss side effects and management of these therapies. Accreditation/Credit Designation Physicians' Education Resource®, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Physicians' Education Resource®, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Acknowledgment of Commercial Support This activity is supported by an educational grant from Jazz Pharmaceuticals, Inc. Link to gain CME credits from this activity: https://www.gotoper.com/courses/from-bench-to-bedside-paradigm-shifts-in-her2-metastatic-btc-treatment Follow us on social media: •⁠  ⁠X/Twitter: https://twitter.com/oncbrothers •⁠  ⁠Instagram: https://www.instagram.com/oncbrothers •⁠  Website: https://oncbrothers.com/ Don't forget to like, subscribe, and hit the notification bell for more updates from the Oncology Brothers!

Dana In The Morning Highlights 5/1Houston Rockets win Game 5 vs Golden State - Game 6 tomorrow night in CaliforniaMD Anderson Children's Cancer Hospital hosts patient prom with New Orleans themeSome say being in love makes them less productive at work

In this episode, Dr. Jennifer Bickel, Chief Wellness Officer at MD Anderson Cancer Center, shares insights into how she's working to build a system-wide culture of well-being. She discusses the importance of operational changes, the development of a Wellness Institute, and tailored strategies to support oncology staff facing emotional and systemic challenges.

Special Patreon Re-Release: Love and Loss with James Jetton   James 1:2-4 (NIV) "Consider it pure joy, my brothers and sisters, whenever you face trials of many kinds, because you know that the testing of your faith produces perseverance. Let perseverance finish its work so that you may be mature and complete, not lacking anything."   **Transcription Below**   James Jetton's Bio: My name is James Jetton. I have and still do live a crazy beautiful, challenging, and blessed life. I am blessed to get to raise 4 beautiful children, and I have spent time getting to serve a fantastic community as a Recreation Minister, where I got to combine my love of Jesus, sports, and people. I served in this role for 13 years before my bride Kaetlin was diagnosed with Leukemia in 2020. Unfortunately, after an awe-inspiring journey with cancer, Kaetlin went to meet her Savior in January of 2022.   Clearly, this changed so much of my life trajectory. Currently, I'm working towards obtaining a Masters in Social Work to take the pain and experiences I have had to help others through their pain. Kaet and I were married in 2009 and built a beautiful life; we taught each other so much. So, I deeply desire to take everything we learned together and the lessons the Lord has taught me to help others.   I mentioned earlier that I have 4 exceptional children, Laken, 9, Isla Kaet, 7, Hattie, 6, and Ryder, 4. Laken is my go-getter; she is fearless, strong, and tough. Sweet Isla Kaet is a quiet thinker and planner and is often referred to as little Kaet. She cares deeply and is always looking for ways where she can help and take care of her family. Hattie is our child with special needs and has been diagnosed with GNB-1 Syndrome (a rare genetic disorder). Hattie will light up any room she is in; it's incredible that a child who only has a few words, uses a wheelchair, and is “limited” by our world's standards, can bring joy to people in a way that I never knew was possible. Ryder the caboose is a maniac, and his sisters affectionately call him “Wreck it Ryder” he has no fear and is a super extrovert; he keeps us all on our toes. He is what some would say, “all boy.”   This is a brief bio of me and our circus; through everything, we have found joy in all circumstances. Although there are exceptionally hard days as we have endured much grief, God has always provided, and I am thankful for the life God has given us.   Questions we discuss: Life took an unexpected twist in 2016. Will you catch us up on your discoveries that year? While many of us were in the midst of changing schedules and suddenly homeschooling children in May of 2020, your family was receiving even more news. Will you share that with us now? What is life like for your family these days, as grief likely comes at unexpected times?   Thank You to Our Sponsors: Chick-fil-A East Peoria and The Savvy Sauce Charities (and donate online here)   Connect with The Savvy Sauce on Facebook or Instagram or Our Website   Please help us out by sharing this episode with a friend, leaving a 5-star rating and review, and subscribing to this podcast!   Other Episodes from The Savvy Sauce of God's Faithfulness: 17 Being on Both Sides of Forgiveness with Adelle Dickie 18 Clinging to Jesus as I lived Through My Worst Nightmare with Angela Braker 19 Grief and Triumph and God's Pursuit Though it All with Julie Locke Moore 20 Joy in the Lord Even Through Tremendous Loss…Twice with Rachel Faulkner Brown 62 Unexpected Grief and What Helped Me Through It Can Help You Too with Singer and Blogger, Brittany Price Brooker 78 Parenting the Prodigal Child And God's Desire For Redemption With Mother-Daughter Duo, Claire Stanfill and Tindell Baldwin 79 Radical Business and Radical Parenting with Gary & Marla Ringger, Founders of Lifesong for Orphans 83 Miracles of God with Founder of Midwest Food Bank, David Kieser 120 Our Story for His Glory with Mercedes Cotchery 134 Fashion Meets Faith with Shari Braendel 141 Rescued from Poverty with Norah Birungi 143 Prodigal Story: Sexuality, Drugs, and Scripture with Dr. Christopher Yuan 160 Unleash This Generation with the Power of the Gospel with Greg Stier 161 God Redeems with Hettie Brittz 162 Healing from Spouse's Sexual Addiction with Jennifer Roush 174 Stories of God's Upside Down Economy with Kristen Welch 208 Tremendous Testimony and Adding Spark into Your Marriage with David & Teri Sumlin 223 Journey and Learnings as Former Second Lady of the United States with Karen Pence 229 Escape from Modern Day Sex Slavery with Rachel Timothy Special Patreon 28 Re-Release: What to Do When You Don't Like Your Story with Sharon Jaynes 231 Stories Series: Faith Building Miracles with Dave Pridemore 232 Stories Series: Testify to Glorify with Richard Gamble 233 Stories Series: Surprises from God with Tiffany Noel Special Patreon Re-Release: Patreon 30 Story of Perseverance with Jenny Boyett 234 Stories Series: Redemption From Sexual Sin in Marriage with Garrett and Brenna Naufel 235 Stories Series: Ever-Present Help in Trouble with Kent Heimer 236 Stories Series: God's Power and Light with Jaime Farrell 237 Stories Series: Prodigal and Redemption with Renee Endress Special Patreon Re-Release: Patreon 31 Unexpected Story of Trauma, Anxiety, Adoption, and Hope with Bettina Stevens 238 Stories Series: God Delights in His Children with Brad Habegger 239 Stories Series: Experiencing the Supernatural with Jackie Coleman 240 Stories Series: God's Rescue and Covering in Parenting with Brenda Dugger 241 Stories Series: From the Mission Field, Experiencing God in the Little and the Big with Patty Sommer 242 Stories Series: He Gives and Takes Away with Joyce Hodel 243 Stories Series: Angel Encounter and Hearing from God with Mary Beth Zimmerman 244 Stories Series: Medical Marvels with Carolyn Henricks 245 Stories Series: Miracles Big and Small with Dr. Rob Rienow 246 Stories Series: Experiencing God's Tangible Love with Jen Moore 247 Stories Series: Exciting Adventures Follow Radical Obedience with Susan Zobrist 248 Stories Series: Discipline of Celebration in the Midst of Unexpected Loss and Grief with Jonathan Pitts Special Patreon Re-Release: Patreon 49: Story of Healing from Sexual Betrayal in Marriage: An Interview with Bonny Burns 249 Stories Series Conclusion: Now What? Living as Global Christians with Todd Ahrend of The Traveling Team   Gospel Scripture: (all NIV)   Romans 3:23 “for all have sinned and fall short of the glory of God,”   Romans 3:24 “and are justified freely by his grace through the redemption that came by Christ Jesus.”   Romans 3:25 (a) “God presented him as a sacrifice of atonement, through faith in his blood.”    Hebrews 9:22 (b) “without the shedding of blood there is no forgiveness.”    Romans 5:8 “But God demonstrates his own love for us in this: While we were still sinners, Christ died for us.”    Romans 5:11 “Not only is this so, but we also rejoice in God through our Lord Jesus Christ, through whom we have now received reconciliation.”    John 3:16 “For God so loved the world that he gave his one and only Son, that whoever believes in him shall not perish but have eternal life.”   Romans 10:9 “That if you confess with your mouth, “Jesus is Lord,” and believe in your heart that God raised him from the dead, you will be saved.”    Luke 15:10 says “In the same way, I tell you, there is rejoicing in the presence of the angels of God over one sinner who repents.”   Romans 8:1 “Therefore, there is now no condemnation for those who are in Christ Jesus”   Ephesians 1:13–14 “And you also were included in Christ when you heard the word of truth, the gospel of your salvation. Having believed, you were marked in him with a seal, the promised Holy Spirit, who is a deposit guaranteeing our inheritance until the redemption of those who are God's possession- to the praise of his glory.”   Ephesians 1:15–23 “For this reason, ever since I heard about your faith in the Lord Jesus and your love for all the saints, I have not stopped giving thanks for you, remembering you in my prayers. I keep asking that the God of our Lord Jesus Christ, the glorious Father, may give you the spirit of wisdom and revelation, so that you may know him better. I pray also that the eyes of your heart may be enlightened in order that you may know the hope to which he has called you, the riches of his glorious inheritance in the saints, and his incomparably great power for us who believe. That power is like the working of his mighty strength, which he exerted in Christ when he raised him from the dead and seated him at his right hand in the heavenly realms, far above all rule and authority, power and dominion, and every title that can be given, not only in the present age but also in the one to come. And God placed all things under his feet and appointed him to be head over everything for the church, which is his body, the fullness of him who fills everything in every way.”   Ephesians 2:8–10 “For it is by grace you have been saved, through faith – and this not from yourselves, it is the gift of God – not by works, so that no one can boast. For we are God‘s workmanship, created in Christ Jesus to do good works, which God prepared in advance for us to do.“   Ephesians 2:13 “But now in Christ Jesus you who once were far away have been brought near through the blood of Christ.“   Philippians 1:6 “being confident of this, that he who began a good work in you will carry it on to completion until the day of Christ Jesus.”   **Transcription**   Music: (0:00 – 0:09)   Laura Dugger: (0:09 - 2:07) Welcome to The Savvy Sauce, where we have practical chats for intentional living. I'm your host, Laura Dugger, and I'm so glad you're here. I'm grateful for today's sponsor, Chick-fil-A East Peoria.   Check them out online to place your order for dining or catering, or to fill out an application to join their friendly team. Visit cfaeastpeoria.com. If you've been with us long, you know this podcast is only one piece of our nonprofit, which is The Savvy Sauce Charities.   Don't miss out on our other resources. We have questions and content to inspire you to have your own practical chats for intentional living. And I also hope you don't miss out on the opportunity to financially support us through your tax-deductible donations.   All this information can be found on our recently updated website, thesavvysauce.com. And now, I'm pleased to share this episode with you that used to only be available to paying patrons.    My guest for today is James Jetton.   Mark and I attended the same family camp as James in 2022. I observed a father who was very devoted to his children, and one of his precious daughters was in a wheelchair, which was always by his side. He was so tender with his children, and I just assumed his wife was resting while he was attending to the family.   I did not learn of his full story until after camp, and it was through a mutual friend, April Siervo. But then, after she shared a bit more of their story, I immediately reached out to James to request that he share his faith and testimony with us today. Here's our chat.   Welcome to The Savvy Sauce, James.   James Jetton: (2:07 - 2:15) I'm happy to be here. I'm looking forward to talking to you and just kind of sharing how God has moved in our lives the past few years.   Laura Dugger: (2:15 - 2:24) You have already lived through so much, but let's just start here. When did Jesus initially draw you to himself?   James Jetton: (2:26 - 3:25) Yeah, I think that's like, you know, it's a big question, right? But also, it shouldn't be. I think the first time I really just kind of came to know the Lord, I was in the eighth grade.   I had a retreat, and in that moment, for me, it was a situation of— it wasn't necessarily for me, but also just trying to do the right thing. I grew up in Birmingham, Alabama, so I was in the Bible Belt. I was like, this is what we're supposed to do.   We're supposed to give our lives to Jesus. But I would say probably going into my senior year of high school, I had some moments just kind of alone at a beach, actually. I was like, what am I doing with my life?   And I believe that that was kind of the first one real moment in my life where I decided, I think I'm going to actually follow the Lord now and not just do this, just to say I'm doing it. And so that was really the first time I really felt the Lord draw me to him. And then, of course, as time goes on, there's all these other little moments throughout where he's continually staying close and bringing me back to him when I feel like I'm drifting away and that sort of thing.   Laura Dugger: (3:27 - 3:39) Thank you for sharing that. And you've written before on your blog that, I'll quote, one of the best decisions I have ever made was when I persuaded Kaetlin to marry me, end quote.   James Jetton: (3:39 - 3:40) Yeah.   Laura Dugger: (3:40 - 3:43) James, how did the two of you meet and fall in love?   James Jetton: (3:44 - 5:30) Yeah, so we went to college together. We went to Troy University. I vividly remember a time where she was getting out of her car, and she didn't know me at this time.   But I remember seeing her. I think I met her maybe once or twice through some mutual friends. I remember seeing her get out of the car and literally, I'll never forget this moment.   I was like, man, if I could just have a girl like that. And it stuck with me. And I think the first time we met, I think I made some comments that she wasn't happy about, about some fraternity guys that were in a different fraternity than me that I didn't think too highly of.   But I didn't realize in that moment that she was actually the sweetheart of that fraternity. And so, we kind of got off to a little bad step there. But I remember she broke up with another boyfriend.   That was part of the reason I saw her. And I was like, I could never have a girl like that. All the girls like that are taken.   And so, she broke up with her boyfriend. I remember her best friend called me and was like, “Hey, can I bring her over to y'all's house? Because she just needs to laugh”.   I was like, “Well, we can do that. We can make sure she laughs”. And so, I think from there, we just kind of, I don't know, just we continued to talk.   And for some reason, she liked me a little bit and I liked her a whole lot. And we dated for about three years in college. And when we got out of college, we got married in May of 2009.   And so that was kind of where life began to speed up a lot at that point. But that was the first time I'll never forget those moments. And then there's other things throughout.   But I remember seeing her in the parking lot like that girl.   Laura Dugger: (5:31 - 5:43) So, I love that. And OK, so married in 2009 and then children came a little while later. So how many children did you add to your family?   James Jetton: (5:44 - 6:28) Yeah, we have four kids. Our first child was born in 2013. So, after we got married, we lived back here in Niceville for a little bit but then ended up moving.   She wanted to go to PA school, and I was working a job I didn't care too much for. So, I was like, how quickly can we go to school? And so, we moved to West Tennessee where she went to PA school.   And I ended up going to school there, too, because she studied all the time, and I was bored. And I was like, I guess I should do something productive as well. So that was 2009 and we had a lot of fun.   We love to travel, did a lot of fun things. And then in 2013, we had our first child, Laken.   Laura Dugger: (6:28 - 6:39) And then if you fast forward, life took an unexpected twist in 2016. So, will you catch us up on your discoveries that year?   James Jetton: (6:40 - 13:07) Yeah. So, we, you know, so we had Laken in 2013. Then, we had another part of our - we did have a miscarriage between Laken and Isla who was born in 2015. But then we had Hattie who was born in 2016.   And Hattie's our child with special needs. And she was born in - all of our pregnancies where we used to joke with people that could have babies and just bounce right back and have these beautiful, wonderful pregnancies. And they loved it.   That was not us. Every single one of our pregnancies brought some challenge within it. And so with Hattie, my wife started swelling a lot and kind of found out she had some clotting in her legs.   And so, we ended up having to induce labor for her with that happening. And, you know, when she my wife was also a PA in the ER. So, she understood medical things way better than I did.   I was kind of oblivious to a lot of things. So, she would probably say it was a little bit more scary than I realized it was when she was giving birth. But when Hattie came, like in some accounts, it just kind of seemed normal.   But she was having some trouble breathing. And so, she was in our hospital. In order to go to the NICU, you have to kind of get transferred out to a smaller hospital.   And so, they were keeping her under observation that night. And her breathing wasn't really getting a whole lot better. And they did x-rays and stuff like that, but couldn't really find much.   And then there was a morning where we were about ready to load up and send her to the NICU. And Kaetlin went and held her. And when she went and held her, she started breathing better.   And she calmed down. And it was kind of crazy. It was genuinely like the love of a mother.   Just like this connection seemed to just calm Hattie down. But we ended up finding out later, one of the nurses was amazing. And was like, I think that she has a broken collarbone.   They didn't see it on the x-ray at first because of the way her chin was turned. And so, when they went back and looked, they did another one. And sure enough, she did have a broken collarbone.   So, at the time, we kind of thought that was kind of the reason for her distressed breathing and that sort of thing. And she had trouble latching and sucking. And what we kind of came to find out later is she had what would be called hypotonia.   Which is basically where the best way to describe it in layman's terms is like a floppy baby. Like you hold her up and everything just kind of flops. And I remember Kaitlyn going to her four-month appointment.   And her being very concerned like, “Hey, Hattie's not meeting milestones. And I think that this isn't going to be a good appointment”. And sure enough, the doctor agreed.   We've always had amazing doctors around us. And so, he agreed. And so, we got referred to neurology.   And another just cool story about how God just provides. One of my best friends growing up, his dad was a neurologist in Birmingham. And so, I called him.   And he's like, all right, I got it. You're going to be here next Thursday. I'm like, oh, okay.   When we were kind of told like it's going to be like three or four months before we can even get you into a neurologist. And so, like God just kind of provided that. And we started that journey of trying to figure out what's going on.   And anyone who's ever had a special needs child, especially when you don't know what it is. Because there was nothing we could have done to foresee this happening. What Hattie had was called DeNovo, like just completely her.   Didn't come from me. Didn't come from Kaylin. And there's no other kids with special needs in our family.   It was just something we couldn't have expected or planned or could have even seen or anything like that. And so just kind of going through a lot of different doctors and tests and eventually getting referred to Johns Hopkins in Baltimore. Because at the time they thought it might be a neuromuscular thing.   And so, from there, they're like, oh, we don't think that's what it is. But then we ran a whole bunch of genetic panels. And like you're just going through all of that.   It definitely there's waves, right? Like it's like you want an answer, but at some level you're afraid of the answer. So, like each time we would do testing stuff before nothing would ever come back.   And so, it was like a relief. Okay, well, good. It's not that one.   Okay. Not that one. But then you're still like, well, what is it?   And so, after we went to Baltimore, they did much more extensive genetic testing. We found out she had this genetic disorder, or syndrome is what they're calling it now called GNV1. And it's crazy rare.   Like at the time, there were only 64 known cases. It was discovered in 2016. So, there's chances that there's other kids out there with it.   I think now there's a little over 100 that they know of. We're part of like a Facebook group where there's some of them in there. And so that's what we got the diagnosis for Hattie.   And so, what that means, I guess, probably no one knows what GNV1 is. Not even doctors. We go to doctors like, oh, can you tell us what this is?   We'll do our best. But it just starts out as hypotonia and global delay, which means every aspect of her is delayed from speech to gross and fine motor movements and all that kind of stuff. And also like with kids with special needs, it doesn't seem to affect any one of them the exact same way.   And so, but the thing about Hattie is like she has an infectious smile. She has this joy that is unreal. Like anybody that meets her just can't get enough of her.   And that is true in so many ways. Hattie uses a wheelchair to get around and Hattie's expressive language. So, her ways to communicate is behind.   But she understands everything. I mean, everything, which is pretty amazing, is my understanding. Not all the kids have that ability to receive and understand things as well as she does.   But she is an absolute joy. We used to always say and still do that Hattie's going to change the world. And we know the fact she's changed my world for sure.   And we know she's changed many others. But yeah, I could keep going on and on. But where we are today, like genuinely that she is a purpose and a reason why I've got to get up every single day.   Yeah. So, she's pretty amazing. Like I'm just yeah, I could go on and on about her.   Laura Dugger: (13:08 - 18:15) I think you described her so well with an infectious smile and joy is the word that comes to mind when you see her. Yeah. And now a brief message from our sponsors.   I want to say thank you to our longtime sponsor Chick-fil-A East Peoria. I hope that you've already downloaded the Chick-fil-A app. Because did you know that with the app you can skip the line and have food ready for you when you arrive?   This is one of my favorite options when I'm taking my four daughters to Chick-fil-A East Peoria. Download the Chick-fil-A app today and start earning points toward free rewards that are fully customized to your preferences and tastes. Chick-fil-A was named as one of Glassdoor's best places to work in the nation.   That's a huge honor. And one team member even wrote, no comparison. This is a great job for a first job, extra money or for career advancement.   Such a loving environment, great management and fair pay. Chick-fil-A believes that the local and involved ownership ensures fostering an environment where you are known, challenged and cared for. So, if you're looking for a wonderful place to work, visit Chick-fil-A East Peoria or fill out an application online today at cfaeastpeoria.com.   Are you utilizing Savvy Sauce Charities to full capacity? Other than our special Patreon re-release episodes, our content is now available in video form in addition to our audio only. And we have written transcriptions for every episode.   Visit our website today, thesavvysauce.com, to access all these forms of interviews. And while you're there, make sure you sign up for our email list to receive encouragement, questions and recommended resources about once a month to promote your own practical chats for intentional living. 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Your financial support furthermore will help us continue to expand our reach and secure future projects we have planned for this ministry.   If your ears are hearing this message right now, I am specifically asking you to give. We are so grateful for any amount and our team will continue to seek to be good stewards of the gifts offered to us. So, if you want to write a check or set up an ongoing payment with your bank that delivers a check to us each month, this is the most beneficial way to give because no percentages are taken out for processing fees.   You can make your checkout to: Savvy Sauce Charities, P.O. Box 101, Roanoke, Illinois, 61561. Additionally, with our new website, we now have a donate button. There are processing fees that we cover for these donations, but we wanted to offer listeners a seamless way to share their finances with us when we share our content with them.   So just visit thesavvysauce.com and find the donate page under the tab support. Another way to find it is simply type in donate to the search bar on our website and just click the first picture shown. We are all about sharing around here, sharing resources, sharing joy, and sharing the good news about Jesus Christ.   We ask that you also will share by sharing financially, sharing The Savvy Sauce podcast episodes, and sharing a five-star rating and review. You can also share any of our social media posts on Instagram or Facebook. We are grateful for all of it, and we just love partnering together with you. Now, back to the show.    In a different season, when many of us were in the midst of changing schedules and suddenly homeschooling our children in May of 2020, your family was receiving even more news. So, will you share that with us now as well?   James Jetton: (18:16 - 22:36) Yeah. We did have our fourth kid, Ryder. He was born in 2018, and he is a wild man.   My wife and I used to always say, or people would tell us, you'll know when you're done. But we had him, and we were like, okay, we're broke. We're done.   No more. But he's awesome. But yeah, the move forward to then, you know, that COVID stuff was really hard.   It was really hard. I was working for a church, and I do sports and rec ministry, and also I was doing student ministry at the time. And so, for me personally, like, things just kind of got shut down.   No one was doing sports leagues, and student ministry looked weirder than ever. And then my wife, she was working in the emergency room as a PA, and so she was facing everything head on. And so, I guess that kind of started in March.   It's funny, just to kind of back up a little bit. We felt prior to that, probably February or March of that 2020, when things were kind of like exploding, we just felt the Lord doing something in our lives. We felt like He was preparing us for something.   We felt like it was going to be something just amazing. But then as we moved forward to try to understand what God is doing, what He was telling us, in May, my 4-year-old, she had her preschool graduation. And I'll never forget this day.   My wife was a go-getter. She's tough. She's strong.   And we had a super weird COVID graduation for Isla, my 4-year-old. And it was weird because it was a drive-through graduation, so we had to get up there early and go do it. So, my wife also, she would do work night shifts so that she could be home with the kids when I couldn't be there.   And so, it wasn't uncommon for her to have to sleep in some. But this was like she hadn't worked the night before, and she hadn't worked. And so, we'd been off for two days, but she was just so exhausted.   She had this terrible headache that morning. And for her to say, like, I can't go to the graduation, that was like, there's something significant here. And I told her, like, she had gone to the doctor about a week before and got on some antibiotics, but it wasn't doing anything.   And I was just like, hey, I think it's time to go back to the doctor because you're not any better. And I've got to take these kids to this graduation. So, I loaded up all the kids.   We went to the drive-through graduation. While I was there, she called and said that her sister was going to take her to the emergency room. So that was a long day.   At that time, COVID was full on, so she couldn't have visitors. No one could come in with her. She had to be dropped off and go inside.   One huge plus in that for our specific situation is that she was taken to her own emergency room. So, she still had her friends and what she would call family there as well. And so, she dropped her off.   My sister-in-law dropped her off and just kind of waited in the parking lot until we figured out what was going on. So, it kind of went throughout that whole day. And I remember that night, the school was doing another virtual graduation where they showed pictures and that sort of thing.   And she texted me and said, I need to talk to you now. I was like, okay, like right now? Because I'm home alone with all four of the kids.   She's like, yeah, and I need you to get away from the kids. I was like, this doesn't sound good. What could this be?   And so, we FaceTimed, and that's where she told me they think I have leukemia. And so then as things started speeding up, we sent out a message to our church asking for prayers. From there, I put the kids to bed.   I drove to Pensacola. She got transferred to Pensacola, and we started treatment there for leukemia. So that was what happened.   That was the big moment in May. And then from there, there's a whole lot more. And so, I'll share as you wish.   Laura Dugger: (22:37 - 22:54) Wow. Thank you for catching us up to that point, James. I can't even imagine the initial devastation that comes.   And as your journey unfolds, I remember seeing a post about leaving your light on.   James Jetton: (22:54 - 24:24) Yeah. Like I said earlier, my wife always did the night shift. And so, I always left the light on for her when she was at work and then turned it off when she came home.   And so, yeah, so early on, I said that I'm not turning the light off until you come home. And so, during that time, the first treatment, it doesn't seem like a lot now because she was in the hospital so much. We didn't know how long she'd be in there.   But the first initial treatment, they're like, you're going to be in for three weeks. And so, I knew that she wouldn't be home for three weeks. And I guess this is me just kind of realizing that was a long time for the kids.   I remember talking to a friend of mine who was leading a small group of high school boys. And I remember him telling them, like, how hard do you think it would be if your mom was gone for three weeks? I was like, yeah, it's not easy.   But so. So, yeah, so that was that was the reason. Just like my wife, one, she was a light in the midst of all the darkness that she was having to face.   And I just wanted to make a point that like, hey, we're leaving this light on for you until you come home. And in a lot of respects, you know, she did go home. Long, long story.   But, yeah, that that was the reason for the light.   Laura Dugger: (24:25 - 24:34) So, well, and the way that you describe her, it sounds like our mutual friend April said her joy was just out of this world.   James Jetton: (24:34 - 24:36) Yeah, that's true.   Laura Dugger: (24:36 - 24:49) It sounds like maybe the both of you share that, but you were not entering into a joyful season. So, what did the next few months and year even look like?   James Jetton: (24:49 - 30:47) Yeah. So initially, when things went down, my wife and I agreed that we would not let our kids lose both their parents. And so, I tried to make it a point to be home at night.   So, when we were in Pensacola, like I would stay with her some nights, but I would also be home at night to put the kids to bed or I would put the kids to bed and I'd drive over that night and come back in the morning or be with her during the day. Like, you know, it was just crazy stuff. One, you know, it happened at the end of the school year.   So, we have all the kids at home. We didn't get to send them off to school. We were blessed to have an amazing college student.   It was one of Kaetlin's girls that she got to mentor when she was in high school. She was an amazing girl. She decided she would be like our nanny that summer.   And so, she was with our kids all day, every day. So, I could go and be with Kaetlin during the day and come home at night. And so, we went through that.   We were here and we did the treatment in Pensacola. It didn't work. And so, the next step at that point was like, well, what are we doing now?   And on a Thursday, the doctor was like, I think we need to go to MD Anderson. We'll see if there's a spot. And then on a Friday, they had a spot.   And then on Monday, we were in Houston at MD Anderson. I went to MD Anderson with her. You know, COVID protocol there still.   I could only be with her for 14 days and inpatient. And then I had to leave as an inpatient. So, I can only go with her for 14 days in that initial time.   And so, we went there. She started a treatment plan. We found an apartment.   And then I left. And then her dad came. And her dad was huge in a lot of this stuff and was able to allow us to do things like me and be with the kids.   And so, I think I stayed there for 10 days. And then he came over to stay with Kaetlin to take her back and forth to the hospital, just receiving treatment. And then I came home, and I came back to Niceville.   And that was during the summer. July, we were at home. We stayed in Niceville just kind of waiting to see, like, is Kaet going to be there longer?   Or is she going to be coming back here? And that was a wild summer. And this is what I think I would tell a lot of people that are going through hard things.   Like just because you're going through hard things doesn't mean there's other hard things. They're just a part of life. And, you know, when you have four kids, stuff happens.   You know, like we had one of my daughters, Isla, she had to have eye surgery that summer. While Kaet was in Houston. So that was an interesting thing.   My four-year-old son, he busted his head open on the back of a step going outside. So, he had to have some stitches in his head. He's the second that has had stitches in our family.   And he was the youngest. So, then the treatment, the goal was to get her to a place where she could do a bone marrow transplant. And so, we got, they got her to that point.   Her leukemia cell counts were low enough that we're ready to do a bone marrow transplant. And at that point, you know, we decided we're going to move to Houston. Everything was virtual at that time.   And I just couldn't see any reason why we couldn't all be together in Houston. And so, we found an apartment, we hunkered down. It's a two-bedroom apartment.   We built some makeshift bunk beds. And so, we moved there in August. And the community we have here was unreal.   The support that we have. Like I didn't, we didn't have to make a meal for, I felt like six months, I think. Like it was just crazy.   And people were allowing it and giving us money. So, we didn't have to worry about these kinds of things and what we're doing. And from moving packing boxes, like, I mean, I can't, it's just unfathomable.   All the different things that were put in place for us to do, to do what we did. And I don't think it would have happened without the community that came around us and our church here was great, but I've got to see The Big-C Church. And, and, and it was, it was amazing.   And so, we ended up, we all moved to Houston, and we lived in a two-bedroom apartment. Part of that story is like, you know, it's like, all right, we're doing this. And then talk about kids.   My four-year-old, the one that had also had the eye surgery, she had broken her ankle on a scooter. Like a week before we're going, it was like, are you kidding me? How is this happening right now?   But we had some great friends like, you know, when your wife is involved in the middle of the medical world, it makes access to doctors and stuff a lot easier when you're in a small town, like we are. So, they got it taken care of, got her in a cast. I was like, yeah, but we can't return with this hard cast.   We're going to Houston. He's like, all right, we'll get her in a hard cast. And we'll put her in a boot for the rest of the time.   So, we moved there. And you know, the dreams of like riding scooters around downtown Houston and doing all this kind of stuff kind of went away a little bit with the kid. And so, he, but there was a pool there.   So, we went swimming, she could swim. And so, we, we just made the best of what we had. Like we, we had a lot of good memories in that little apartment, even though it was, it was tough.   I remember, we, Halloween wasn't too long ago. We had our own little Halloween party in that apartment where we all dressed up, even Kaet. Cause she ended up getting her bone marrow transplant that time.   And another aspect of where dad was so important is when you get in the bone marrow transplant, you cannot leave, and you can have one guest. And so, her dad came and he stayed with her. It was about 30 days of bone marrow transplant.   And so, he was there with her so I could be with the kids, doing the best I can with that virtual school and, and managing Ryder and Hattie in the midst of trying to do school work with the kids. It's nothing I ever want to go back to.   Laura Dugger: (30:48 - 31:03) Well, and not to mention you appreciate The Big-C Church, but Houston was not your long-term community. So, being here in this new place and all of these transitions, what were the results of her bone marrow transplant?   James Jetton: (31:04 - 40:17) Yeah. So, the bone marrow transplant, it ended up working. She went into remission and so we get to come home Thanksgiving of 2020.   We came home and that was awesome. It was like a huge homecoming. Finally got back home.   She's, she's in remission. We felt like we'd beaten this. We, you know, we got that Christmas here and we were back home.   We even, our family always loves to go, has always gone to North Carolina for vacation every year. And we didn't get to do that. But so, it was like, now we're going.   And so, in January we're like, all right, we're going kids. It was just me and the kids and Kaet and we wanted to go see snow. So, we went up there and we found a place to stay.   It was an awesome trip. Loved it so much. We, when we had to check out of our place, we found another house so we could stay in for a few more days.   And so, you know, at that time though, when we were doing that, she was kind of having these red bumps kind of popping up over her. We didn't really know what it was. It could have been a reaction.   We couldn't figure it out. Saw some doctors here locally. No one could really figure out what it was.   And I think fast forward, what we found out probably, I think it was February. She came out of remission and that was kind of the beginning signs of her coming out of remission. And so that's where, life sped up.   Like, I mean, if it wasn't already fast, it was, it was just unreal. It was like a whirlwind like it was because she had to fly to Houston to go and see her doctors. And so, she was in Houston by herself when she found out that she had come out of remission, and they were going to start immediately.   So, she stays, and she flies over on Friday and on Monday they got her back doing her treatment. And so, and I was like, well, it looks like we're moving to Houston. And I was like, but this time we're not staying in a two-bedroom apartment.   It's like we're going to make this a little bit more manageable for us. So, we had some great family. Kaetlin actually had a cousin who lived in Houston.   We found a house inside their neighborhood that we could rent. And this was, you know, more, more provision that he just continued to show. We found this house in like a week and we had people from our community boxing up everything in our house.   He's gotten a truck, and we thought that we'd all get everything in one truck. But we didn't get everything in one truck. We'd even hired the movers to load up the truck.   They couldn't get it all in there. So, I was like, y'all told me that it would all fit on this truck, but now it's not. And it's Friday at like 5 p.m. when we were supposed to leave tonight. So, we're not leaving. But my brother came down. I had another one of my best friends come down and they were like, we got to go, we're going to make this happen.   So that next morning, I'm not kidding. When there was like 20 to 30 guys in my house, a brother had gotten the truck. I hadn't even, they left early to go with the truck.   I'd come. And I was at the house with the kids at a friend's house. And when me and the kids showed up, these 30 guys had already loaded up the truck and we were ready to go.   Guy came and dropped off a big spread of McDonald's for everybody. We prayed over us and we headed out that morning. And so, it was just, I mean, just crazy that, you know, in one week we packed up a four-bedroom house, loaded up two trucks and drove to Houston and we're now unloading at a new house in Houston.   And, and that's where we were for a while. That was where Kaetlin, then we went back into the treatment more aggressively trying to get her back to remission. And so that was, when we moved there in March of 2021.   And that was kind of our place for a while. We actually thought we'd be there for a real long time. Kids had started school there, trying our best to get connected community there, but it's difficult, especially when you've come from a place where you feel so connected and then you're moving somewhere new where you don't really know anybody.   And then you're moving there in a time where the whole town shut down. It was tough, but we got the kids back in school. We tried to start getting them back into normalcy of life.   And there's all these new trials when you're going through this stuff every day, it seems like there's a new trial. MD Anderson is amazing. They treat each patient. It's like an individual.   So, every plan they have is just specifically for that patient. And so, they were going to try to do this CAR T-cell treatment. So, we'd kind of gone through the whole summer, and then we get to the point where she's going to do her CAR T-cell treatment.   Now, you know, we, we were hunkered down with this COVID stuff. Like we didn't, we didn't do much. We got really good at DoorDash and grocery delivery.   And we, you know, we masked up everywhere we could because Kaetlin's system was so immuno-compromised and we had done what we had thought was a very good job of keeping her safe, keeping everyone safe. Well, and then she got to the point where she was ready to start this new trial with CAR T-cell treatment. And she gets admitted that night and every time they go in and they give her a COVID test, well, that night she had COVID.   And it was, it was like, what? And she didn't feel bad. Her dad had gotten it too.   Like we, and I, so I remember getting that, it was like one o'clock in the morning. I was asleep. I remember it like blowing up my phone.   And I was like, I didn't realize it until later. And I talked to her. And that was definitely a tough conversation because she had to like get moved, packed up and moved out and moved to a different place and then treatment for the COVID stuff.   But the crazy part was, and it was kind of, you know, I wanted to get frustrated about things I could, but like, she had zero symptoms and she had just tested positive. And so, the next morning we all had to go get tested. And it was just the weirdest thing.   I know that COVID has been so devastating to so many people. But in that moment for us, it was like, we don't like, I was like, I ran nine miles yesterday and now I'm positive for COVID. I don't.   And so, but what it did was it kicked her out of the trial that she was on. And so, then she had to come home. The next process was just kind of getting her ready for that same thing.   Basically, what her doctor did was like, I'm not taking out, you're going to get kicked off the trial, but I'm just going to make you my own individual patient. We're going to do it that way. And so, we had some, we had some pretty high hopes for this.   Doctor seemed pretty optimistic about this plan. And so, we had been renting our house in, in Niceville. And with this new plan, I would have had Kaetlin there for like three years.   And so, we were like, you know, do we really want to rent our house anymore? It's like, no, we don't. All right, well let's sell our house.   So, we sold our house, and it sold in like less than 24 hours. And it's like $25,000 over asking price. It was like, well, okay, God, I feel like that's what we're supposed to do.   And so, she went in to get that treatment. And, and, uh, unfortunately, uh, we found out that didn't work. Uh, it was like, well, she can't remember coming home and saying like, well, I'm ready.   I want to go back home. I was like, what? We just sold our house.   We don't have a home right now. But God always makes a way and you always provide always. Um, and so we, you know, I was like, all right, we want to go home.   We're going to go home. And at first I was being very logical. I was like, well, let's let the kids finish out the semester.   Cause this was like around Halloween is when she realized it didn't work and we're going to come home. So, we were able to come home. We had some amazingly generous friends who they got us a private flight to come home for that Halloween.   And I guess when we were there, um, that's where we really just decided we need to be back. And, and so she, when we went back to talk to her doctors about managing her leukemia remotely. And so that was what the plan was.   So we, we moved back that Thanksgiving, uh, with all of our stuff and we were looking for a place to stay. It was actually kind of a fun month. We were living on the beach for a couple months or really from Thanksgiving to right before Christmas.   We had some pretty awesome things come available. We were able to live in a house on the beach. And so that was, that was mine and my wife's always kind of like a special place.   And so, we love the water, and we love the beach. And so that was an awesome place for us to be. And so, uh, coming back, it was tough.   She was getting out of the hospital a lot just with fevers and stuff like that. And then we got to have Christmas here that December. And then January 9th of this past year, she, she, uh, eventually passed away.   We weren't expecting, I mean, we knew that there would be an end, but I don't think we could have expected it to, um, happen then. And I think we kind of thought we'd have a little bit more time, but we didn't, but we were thankful. I'm thankful for my wife.   It was like we got to get back now because we knew that when an issue did pass that we needed to be in our hometown and not in Houston, where our community was much smaller.   Laura Dugger: (40:18 - 40:27) So, yeah. And so, you're together, you're celebrating Christmas. And then things suddenly turned unexpectedly.   James Jetton: (40:28 - 40:28) Yeah.   Laura Dugger: (40:28 - 40:31) And that led to losing her on January 9th.   James Jetton: (40:32 - 44:59) Yeah. You know, nothing really happened like, you know, in that leukemia world. And you know, a lot of cancers that give you like, you know, a prognosis like, you have three months, you have four months full, but blood cancer is very different.   And it kind of exacts you and, and there's no way to really know for sure, like, is this going to work or how long do we have and that sort of thing. And she was just in and out of the hospital so much. When we came back home, when you have leukemia, anytime you have a fever above a hundred point four, it's like you're immediately going to the doctor.   And so that's kind of how, you know, when she went in, like, there's still kind of an expectation that she would come home. But then those last few days, like, I just, I vividly remember as we're trying to figure out what to do, we're going to, are we going to go to a new treatment plan or we're going to try something else? Or, or is this kind of the end?   And her doctor here, he said, there was a plan that we possibly could have done, but he was like, they're saying this got a success rate of like, whatever, nine of 10 people went into remission with it. He's like, but when you look closer, they were only in remission for four weeks. And he was like, is this what we want to do?   Cause chemo just, it wipes you out. And it's like, there's no way to continue to live like this. But she, Kaetlin, she was, she just had a way of bringing a peace over everybody.   She had a way of like knowing exactly what everyone needed, I guess, in some respects. Cause I remember leaving the day we decided we would not do the treatment plan. And I came home, like I said, I always try to be home to put my kids to bed.   She said that the night before it kind of, she went downhill fast. She got up and walked around the hospital with her dad and told her dad like, “Hey, I think I'm going to do, I think I'm going to do it. I'm going to do the treatment plan.”   You know, I've talked to him about this, but I feel like that was almost like the piece he needed to go home. You know, when she passed, it was like, it was beautiful. Like it was, it was such a blessing that she was in her home hospital and that the doors, it was like a revolving door.   I remember Kaetlin told me once, she said, “when I pass or when I'm in the last days, don't tell anyone that they can't come see me.” And so, we were trying to figure out how we're going to do this. And I was like, well, she said that anybody who wants to come see me, let them come see me.   And so, we put a word out and there was like a revolving door of people just coming in and out of the room all day. Like the doctors, the ER told the front desk people, like, you know, technically, I guess you're only supposed to have like two visitors or something because of the COVID things. And she was like, anybody that comes in and says they want to see Kaetlin Jetton, you say, “Go on up”.   So it was, it was pretty awesome seeing all these people come in and see her. And we had already gotten to see the impact that she had made on so many people's lives for the past couple of years, but it was cool to see them all there doing that. And I remember the night she passed, I leaned over, I was heading home and two of my best friends since the ninth grade had come down and they were at the house with the kids and I was coming home to put the kids to bed.   And I leaned over and gave her a kiss and I said, don't wait on me. It's like, it's okay. It's time to go home.   And sure enough, that's, I left that night and I got a phone call about 11 from her dad and she had passed and that, and I think that, you know, in some respects, it's like, should I have been there? I was like, but I think that also was like, no, Kaet wanted you to be with your two guys. And Kayla knew that her family would be there with her.   And she did exactly what she wanted to do. You know, she always had a plan even from her like celebration service. She had everything written out.   Who's going to speak, what songs are playing, when are we doing this? And so it was, it was, you know, it was pretty cool seeing how many people just came in and out and how she just kind of felt like she knew what she was doing, even up in the last days. So.   Laura Dugger: (45:00 - 45:55) Do you love The Savvy Sauce? Do you gain anything when you listen? Did you know that the two ways we earn money to keep this podcast live is through generous contributions from listeners and from our paying sponsors.   That means we can promote your business and you're still supporting The Savvy Sauce. It's a win-win. Please email us today at info@thesavvysauce.com to inquire about pricing for sponsoring each episode. Thank you for your consideration.    Well, James, your perspective is incredible. And yet I'm so sorry, such a deep loss for your whole family.   And what is life like now for all of your family these days? Cause it's still very recent. And I'm wondering if grief still comes up at unexpected times.   James Jetton: (45:56 - 50:49) Yeah. You know, it's, you know, it's a day-to-day thing, I believe. I don't, and grief is certainly something that sometimes you don't see it coming.   And I'll say, I love bragging on this community. I love bragging on this town so much. So, my kids, they're all in school, you know, and I'm bragging on my kids too.   After she passed, the kids got to stay home for a couple of weeks, but then it was time to go back to school. My two girls go to one school where actually Kaetlin went to school from kindergarten all through. So, I felt like that was a very special thing for her and the kids could go to the same school that their mom went to.   But then Hattie goes to a different school because of her special needs. And then Ryder goes to a different school. He's in preschool.   And so, after she passed, like, so it was complicated in the sense of, I've got to get Hattie to school at 7:30. I've got to get Lincoln out of school by like 8:45 and then Ryder can go in before 9:00 a.m. So, I would usually drop him off on the way. But I say, I'd say like, what does life look like?   Well, after she passed, I knew like, how am I going to make this work? And that semester, there was somebody in my house every morning at 7:00 a.m. to sit with the kids, help with breakfast, and help finish getting them ready while I could take Hattie to school at 7:30. And then I would come back home and after they finished getting ready, then I would take them to school. So, I had someone in my house every morning at 7:00 a.m. after she passed, which was, you know, they were doing it for the kids, but they were doing it for me too. I knew that I couldn't just lay in my bed and let people just come on in and take care of my kids. Like I had to get up, take a shower, look like I'm somewhat presentable and go on. And that's kind of how that last semester was, just community and people with meals and then through all that, trying to get them engaged, get them back into doing some things that they love to do.   And yeah, I like to brag on my kids in a lot of ways, this perspective kind of dawned on me in the past couple of weeks of like, I sent them back into a new school where they know very many people. Everybody knows them. Not everyone.   I don't know everybody. And they had to go and do that a few weeks after their mom passed. Here I am trying to stay away from people and not have a whole bunch of conversations, but yet the kids are stepping up and doing their thing.   And man, it's just, it's pretty inspiring when I think of it in that respect as well. Nowadays we are blessed that we get to have a nanny and it's, that's a whole cool story in itself. And that she worked with me in student ministry, and I'd actually left to go be a nanny for some other people in Nashville.   And I was texting her trying to figure out, “Hey, I need some help. You got any friends down here that want to be a nanny? Cause it's hard to find.”   And she's like, “Actually, I would love to come back and do it.” And that was just a huge blessing. Cause it was like, at the time of us having all these new things, I was able to be able to have somebody that the kids already knew come in and be there.   And so, she helps in so many ways and allows the kids to do their tennis and their soccer and gymnastics or whatever it may be. And it allows me to get to, coach them and be a part of that, those aspects of life, which I love doing so much. And so, she's really helped.   So, in our day to day now, like it, it's a lot of moving pieces. I mean, just last week, we got to go to a widower's retreat and there was never a worry, never worry about who's taking care of the kids, that they're getting to where they need to be. So, it's a genuine, like I get to see how a village truly takes care of the kids.   And yes, there are days and it's hard. And some days it just kind of sucks and it sucks for them. It sucks for me.   But I have gotten to see how God still shows out through the difficult moments and how he still provides no matter how far away I am or how close I am. He still continually provides. And I know that, and I know that he will not let us down.   It's one day at a time. And as we approach these new seasons, there's always new seasons. You talk about grief and things pop up.   I think that holidays will bring up stuff they already have in some respects and my wife, you know, she was a medical professional. So, when kids get sick, it's different now. We go to the doctor more often because mom's not here to take care of them and call in medicine.   But I think that we do sense a void in that when kids are sick and that sort of thing. But, today, like things are okay. We're doing all right.   Laura Dugger: (50:50 - 51:07) Well, and James, you were a journalism major and you're a very gifted writer. So where would you direct us to get to read more about your family and stay current and hopefully find ways that we can further support you?   James Jetton: (51:08 - 52:18) Well, my wife and I, we started a blog called Our Hands Go Up, and it's OurHandsGoUp.com. And that's formed out of, started with Hattie. That's where the blog started because Hattie, we talked about that joy that she has, but our hands will always go up.   Like her hands go up all the time and it just seems so appropriate. And the picture of hands going up, there's so many things that go to that with our praise to God, our vulnerability and our sides. And there's just a lot that comes through that anyway.   But yeah, Kaetlin started writing on that and I wrote some in that. She spearheaded it because she's way more organized and detailed than I am. So, it looks a lot prettier than what I would have done, but here recently, like I've felt a calling to bring it back and revitalize it.   So as of right now, like there's, my wife wrote a lot, and she still has writings that she never shared with anybody. So, I've started revitalizing it by sharing some of her writings, but I will be writing in there as well. So that would probably be a good place or even, and then my, just my social media, James Jetton, you can always see some crazy stories of my kids.   Laura Dugger: (52:21 - 52:34) Oh, wonderful. We will link to both of those in our show notes. And are there any practical needs that you do have at this time or any specific prayer requests you would like to share with us?   James Jetton: (52:35 - 53:26) You know, I think the specific prayer requests are just for me and for my kids. So, things are going to look different for them for sure. And I know there's going to be some hard moments.   So, I guess the prayer would just be, you know, provision as God's always provided. And, you know, when I say that, I don't just talk about it in like a material way, but like He seems to provide us with feelings, emotions, people, support, all of that. And so just provision for my kids and just encouragement and support for them as we've kind of walked through these, these new firsts for the kids and, and that it will just, they will still have, find the joy that we always talk about choosing and, and that my wife did so well that we will continue to find that joy through these more difficult days ahead for sure.   Laura Dugger: (53:26 - 53:58) Yes, Lord may it be so. Well, James, you clearly just have so much wisdom to share and I appreciate you walking through so much of your personal journey. And I know that you also do have a lighthearted personality and we're going to end on a lighter note because you may know that we're called The Savvy Sauce because Savvy is synonymous with practical knowledge.   And so, as my final question for you today, what is your Savvy Sauce?   James Jetton: (54:01 - 54:51) You know, my Savvy Sauce, it's just, it's one day at a time. I think that we get overwhelmed with, you know, I joke with people, like it's a stupid joke. But hey, if God wanted to give us more than one day at a time, He would. So, we only get one day, and He doesn't give us two days at one time.   You know, just taking things as they come one day at a time. We all have our goals. We all have our plans, our dreams and aspirations, but leaving space for the Holy Spirit and how God moves is critical.   And when you're walking through grief and you're walking through hard stuff, like thinking about too much out there in front of you can be debilitating. And so just focus on what your next step, just take one more step. We can always take one more step.   And so just kind of day at a time and just take one more step.   Laura Dugger: (54:52 - 55:08) James, thank you for your faithfulness to Kaet, your faithfulness to our Lord, your faithfulness to your children. And we will all be praying for each of you in this coming season and beyond. And just really grateful for you being my guest today.   James Jetton: (55:09 - 55:26) Well, I'm really grateful to be here. This is great. I'm thankful for the chance to just share her story and share our story.   I feel God has just moved and worked through us in so many amazing ways. And anytime I can get a chance to share how God has moved and worked, I'm thankful. So, thank you for having me.   Laura Dugger: (55:26 - 58:42) It's been an honor. One more thing before you go. Have you heard the term gospel before?   It simply means good news. And I want to share the best news with you. But it starts with the bad news.   Every single one of us were born sinners, but Christ desires to rescue us from our sin, which is something we cannot do for ourselves. This means there is absolutely no chance we can make it to heaven on our own. So, for you and for me, it means we deserve death and we can never pay back the sacrifice we owe to be saved.   We need a savior. But God loved us so much, he made a way for his only son to willingly die in our place as the perfect substitute. This gives us hope of life forever in right relationship with him.   That is good news. Jesus lived the perfect life we could never live and died in our place for our sin. This was God's plan to make a way to reconcile with us so that God can look at us and see Jesus.   We can be covered and justified through the work Jesus finished if we choose to receive what He has done for us. Romans 10:9 says, “That if you confess with your mouth Jesus is Lord and believe in your heart that God raised him from the dead, you will be saved.” So, would you pray with me now?   Heavenly Father, thank you for sending Jesus to take our place. I pray someone today right now is touched and chooses to turn their life over to you. Will you clearly guide them and help them take their next step in faith to declare you as Lord of their life?   We trust you to work and change lives now for eternity. In Jesus' name we pray. Amen.   If you prayed that prayer, you are declaring him for me, so me for him. You get the opportunity to live your life for him. And at this podcast, we're called The Savvy Sauce for a reason.   We want to give you practical tools to implement the knowledge you have learned. So, you ready to get started? First, tell someone.   Say it out loud. Get a Bible. The first day I made this decision, my parents took me to Barnes & Noble and let me choose my own Bible.   I selected the Quest NIV Bible and I love it. You can start by reading the book of John. Also, get connected locally, which just means tell someone who's a part of a church in your community that you made a decision to follow Christ.   I'm assuming they will be thrilled to talk with you about further steps, such as going to church and getting connected to other believers to encourage you. We wa

Listen to ASCO's Journal of Clinical Oncology Art of Oncology article, "Tamales” by Megan Dupuis, an Assistant Professor of Hematology and Oncology at Vanderbilt University Medical Center. The article is followed by an interview with Dupuis and host Dr. Mikkael Sekeres. Dupuis reflects on how patients invite their doctors into their culture and their world- and how this solidified her choice to be an oncologist. TRANSCRIPT Narrator: Tamales, by Megan Dupuis, MD, PhDI do not know if you know this, but tamales are an important—nay, critical—part of the Mexican Christmas tradition. Before I moved to Texas, I certainly did not know that. I did not know that the simple tamal, made of masa flour and fillings and steamed in a corn husk, is as essential to the holiday season as music and lights. Whole think pieces have been written in The Atlantic about it, for God's sake. But, I did not know that. A total gringa, I had grown up in upstate NY. We had the middle-class American version of Christmas traditions—music, snow, Santa, and a Honey Baked Ham that mom ordered 2 weeks before the holiday. I had never tried a homemade tamal until I moved to Texas. We had relocated because I was starting a fellowship in hematology/oncology. A central part of our training was the privilege of working at the county hospital cancer clinic. Because we were the safety-net hospital, our patients with cancer were often under- or uninsured, frequently had financial difficulty, and were almost always immigrants, documented or otherwise. In a typical clinic day, over 90% of my patients spoke Spanish; one or two spoke Vietnamese; and typically, none spoke English. From meeting my very first patient in clinic, I knew this was where I needed to be. Have you ever been unsure of a decision until you have been allowed to marinate in it? That is how I felt about cancer care; I had not been sure that my path was right until I started in the county oncology clinic. I loved absorbing the details of my patients' lives and the cultures that centered them: that Cuban Spanish is not Mexican Spanish and is not Puerto Rican Spanish; that many of my patients lived in multigenerational homes, with abuelos and tios and nietos all mixed together; and that most of them continued to work full-time jobs while battling cancer. They had hobbies they pursued with passion and lived and died by their children's accomplishments. I learned these details in the spaces between diagnosis and treatment, in the steady pattern woven in between the staccato visits for chemotherapy, scans, pain control, progression, and hospice.  In one of those in-betweens, my patient Cristina told me about tamales. She had faced metastatic breast cancer for many years. She was an impeccable dresser, with matching velour tracksuits or nice slacks with kitten heels or a dress that nipped in at the waist and flared past her knees. Absolutely bald from treatment, she would make her hairlessness look like high fashion rather than alopecia foisted upon her. Her makeup was always painstakingly done and made her look 10 years younger than her youthful middle age. At one visit in August, she came to clinic in her pajamas and my heart sank. This was a familiar pattern to me by now; I had taken care of her for 2 years, and pajamas were my canary in the coal mine of progressing cancer.  So on that sunny day, I asked Cristina what her goals would be for the coming months. The cancer had circumvented many of her chemotherapy options, and I only had a few left. “Doctora D, I know my time is limited…” she started in Spanish, with my interpreter by my side translating, “but I would really like to make it to Christmas. My family is coming from Mexico.” “Oh that's lovely. Do you have any special Christmas plans?” I ventured, wanting to understand what her holidays look like. “Plans? Doctora D, of course we are making tamales!” She laughed, as though we were both in on a joke. “Tamales? At Christmas?” I asked, signaling her to go on.  “Yes yes yes, every year we make hundreds and hundreds of tamales, and we sell them! And we use the money to buy gifts for the kids, and we eat them ourselves too. It is tradicio´ n, Doctora D.” She underlined tradicio´ n with her voice, emphasizing the criticality of this piece of information. “Okay,” I said, pausing to think—December was only four months away. “I will start a different chemotherapy, and we will try to get you to Christmas to make your tamales.” Cristina nodded, and the plan was made.  Later that evening, I asked one of my cofellows, a Houston native, about tamales. He shared that these treats are an enormous part of the Houston Christmas tradition, and if I had any sense, I would only purchase them from an abuela out of the trunk of a car. This was the only way to get the best homemade ones. “The ones from restaurants,” he informed me, “are crap.”  So summer bled into fall, and fall became what passes for winter in Texas. On 1 day in the middle of December, Cristina came into clinic, dressed in a colorful sweater, flowing white pants, black boots, and topped off with Barbie-pink lipstick. “Cristina!” I exclaimed, a bit confused. “You don't have an appointment with me today, do you?”  She grinned at me and held up a plastic grocery bag with a knot in the handles, displaying it like a prize.  “Tamales, Doctora D. I brought you some tamales so you can join our Christmas tradition.” I felt the sting of tears, overwhelmed with gratitude at 11:30 in a busy county clinic. I thanked her profusely for my gift. When I brought them home that night, my husband and I savored them slowly, enjoying them like you would any exquisite dish off a tasting menu. Sometimes, people think that oncologists are ghouls. They only see the Cristinas when they are in their pajamas and wonder why would any doctor ever give her more treatment?  My answer is because I also got to see her thriving joyfully in track suits and lipstick, because I got to spend countless in-betweens with her, and because I helped get her to the Christmas tradiciones I only knew about because of her. And in return, she gave of herself so easily, sharing her life, her passion, her struggles, and her fears with me. Caring for Cristina helped me marinate in the decision to become an oncologist and know that it was the right one. And if you are wondering—yes. Now tamales are a Christmas tradicio´n in the Dupuis household, too. Mikkael Sekeres: Hello, and welcome to JCO's Cancer Stories: The Art of Oncology, which features essays and personal reflections from authors exploring their experience in the oncology field. I'm your host, Mikkael Sekeres. I'm a professor of Medicine and Chief of the Division of Hematology at the Sylvester Comprehensive Cancer Center, University of Miami. What a pleasure it is today to be joined by Dr. Megan Dupuis from Vanderbilt University Medical Center. She is Assistant Professor of Hematology and Oncology and Associate Program Director for the Fellowship program. In this episode, we will be discussing her Art of Oncology article, "Tamales." Our guest's disclosures will be linked in the transcript. Both she and I have talked beforehand and agreed to refer to each other by first names. Megan, welcome to our podcast, and thank you for joining us. Megan Dupuis: Oh, thanks so much for having me, Mikkael. I'm excited to be here. Mikkael Sekeres: I absolutely loved your piece, "Tamales," as did our reviewers. It really did resonate with all of us and was beautifully and artfully written. I'm wondering if we could just start—tell us about yourself. Where are you from, and where did you do your training? Megan Dupuis: Sure. I'm originally from upstate New York. I grew up outside of Albany and then moved for college to Buffalo, New York. So I consider Buffalo home. Big Buffalo Bills fan. And I spent undergrad, medical school, and my PhD in tumor immunology at the University of Buffalo. My husband agreed to stick with me in Buffalo for all twelve years if we moved out of the cold weather after we were done. And so that played some factor in my choice of residency program. I was lucky enough to go to Duke for residency—internal medicine residency—and then went to MD Anderson for fellowship training. And then after Anderson, I moved up to Nashville, Tennessee, where I've been at Vanderbilt for almost four years now. Mikkael Sekeres: That's fantastic. Well, I have to say, your Bills have outperformed my Pittsburgh Steelers the past few years, but I think I think we have a chance this coming year. Megan Dupuis: Yeah. Yep. Yep. I saw they were thinking about signing Aaron Rodgers, so we'll see how that goes. Mikkael Sekeres: Yeah, not going to talk about that in this episode. So, I'm curious about your story as a writer. How long have you been writing narrative pieces? Megan Dupuis: I have always been a writer—noodled around with writing and poetry, even in college. But it was when I started doing my medicine training at Duke that I started to more intentionally start writing about my experiences, about patients, things that I saw, things that weighed either heavily on me or made a difference. So when I was at Duke, there was a narrative medicine writing workshop—it was a weekend workshop—that I felt like changed the trajectory of what my interest is in writing. And I wrote a piece at that time that was then sort of critiqued by colleagues and friends and kicked off my writing experience. And I've been writing ever since then. We formed a narrative medicine program at Duke out of this weekend workshop experience. And I carried that through to MD Anderson when I was a fellow. And then when I joined at Vanderbilt, I asked around and said, "Hey, is there a narrative medicine program at Vanderbilt?" And somebody pointed me in the direction of a colleague, Chase Webber, who's in internal medicine, and they said, "Hey, he's been thinking about putting together a medical humanities program but needs a co-conspirator, if you will." And so it was perfect timing, and he and I got together and started a Medical Humanities Certificate Program at Vanderbilt about four years ago. And so- Mikkael Sekeres: Oh, wow. Megan Dupuis: Yeah. So I've been doing this work professionally, but also personally. You know, one of the things that I have been doing for a long time is anytime there's an experience that I have that I think, “Gosh, I should write about this later,” I either dictate it into my phone, “write about this later,” or I write a little message to myself, “Make sure that you remember this experience and document it later.” And I keep a little notebook in my pocket specifically to do that. Mikkael Sekeres: Well, it's really a fabulous, updated use of technology compared to when William Carlos Williams used to scribble lines of poetry on his prescription pad and put it in his rolltop desk. Megan Dupuis: Although I will admit, you know, I don't think I'm much different. I still do prefer often the little leather notebook in the pocket to dictating. It'll often be when I'm in the car driving home from a clinic day or whatever, and I'll go, “Oh, I have to write about this, and I can't forget.” And I'll make myself a little digital reminder if I have to. But I still do keep the leather notebook as well for the more traditional type of writing experience. Mikkael Sekeres: I'm curious about what triggers you to dictate something or to scribble something down. Megan Dupuis: I think anything that gives me an emotional response, you know, anything that really says, “That was a little bit outside the normal clinical encounter for me.” Something that strikes me as moving, meaningful—and it doesn't have to be sad. I think a lot of novice writers about medical writing think you have to write only the tragic or the sad stories. But as often as not, it'll be something incredibly funny or poignant that a patient said in clinic that will make me go, “Ah, I have to make sure I remember that for later.” I think even surprise, you know? I think all of us can be surprised in a clinical encounter. Something a patient says or something a spouse will reflect on will make me sit back and say, “Hmm, that's not what I expected them to say. I should dive into why I'm surprised by that.” Mikkael Sekeres: It's a great notion as a starting point: an emotional connection, a moment of surprise. And that it doesn't have to be sad, right? It can be- sometimes our patients are incredibly inspirational and have great insights. It's one of the marvelous things about the career we've chosen is that we get to learn from people from such a variety of backgrounds. Megan Dupuis: That's it. It's a privilege every day to be invited into people's most personal experiences, and not just the medical experience. You know, I say to my patients, “I think this cancer diagnosis is in some ways the least interesting thing about you. It's not something you pick. It's not a hobby you cultivate. It's not your family life. It's a thing that's happened to you.” And so I really like to dive into: Who are these people? What makes them tick? What's important to them? My infusion nurses will say, "Oh, Dr. D, we love logging in and reading your social histories," because, yeah, I'll get the tobacco and alcohol history, or what have you. But I have a little dot phrase that I use for every new patient. It takes maybe the first five or six minutes of a visit, not long. But it's: Who are you? What's your preferred name? Who are your people? How far do you live from the clinic? What did you used to do for work if you're retired? If you're not retired, what do you do now? What are the names of your pets? What do you like to do in your spare time? What are you most proud of? So those are things that I ask at every new patient encounter. And I think it lays the foundation to understand who's this three-dimensional human being across from me, right? What were they like before this diagnosis changed the trajectory of where they were going? To me, that's the most important thing. Mikkael Sekeres: You've so wonderfully separated: The patient is not the diagnosis; it's a person. And the diagnosis is some component of that person. And it's the reason we're seeing each other, but it doesn't define that person. Megan Dupuis: That's right. We're crossing streams at a very tough point in their life. But there was so much that came before that. And in the piece that I wrote, you know, what is the language? What is the food? What is the family? What are all of those things, and how do they come together to make you the person that you are, for what's important to you in your life? And I think as oncologists, we're often trying to unravel in some way what is important. I could spend all day talking to you about PFS and OS for a specific drug combination, but is that really getting to meeting the goals of the patient and where they're at? I think it's easy to sort of say, “Well, this is the medicine that's going to get you the most overall survival.” But does it acknowledge the fact that you are a musician who can't have neuropathy in your fingers if you still want to play? Right? So those things become incredibly important when we're deciding not just treatment planning, but also what is the time toxicity? You know, do you have the time and ability to come back and forth to clinic for weekly chemotherapy or what have you? So those things, to me, become incredibly important when I'm talking to a person sitting across from me. Mikkael Sekeres: Do your patients ever get surprised that you're asking such broad questions about their life instead of narrowing down to the focus of their cancer? Megan Dupuis: Sometimes. I will say, sometimes patients are almost so anxious, of course, with this new diagnosis, they want to get into it. You know, they don't want to sit there and tell me the name of the horses on their farm, right? They want to know, “What's the plan, doc?” So I acknowledge that, and I say to them in the beginning, “Hey, if you give me five minutes of your time to tell me who you are as a person, I promise this will come back around later when we start talking about the options for treatments for you.” Most of the time, though, I think they're just happy to be asked who they are as a person. They're happy that I care. And I think all of us in oncology care—I think that's... you don't go into a field like this because you're not interested in the human experience, right? But they're happy that it's demonstrable that there is a... I'm literally saying, “What is the name of your dog? What is the name of your child who lives down the street? Who are your kids that live far away? You know, do you talk to them?” They want to share those things, and they want to be acknowledged. I think these diagnoses can be dehumanizing. And so to rehumanize somebody does not take as much time as we may think it does. Mikkael Sekeres: I 100% agree with you. And there can be a selfish aspect to it also. I think we're naturally curious people and want to know how other people have lived their lives and can live those lives vicariously through them. So I'm the sort of person who likes to do projects around the house. And I think, to the dismay of many a professional person, I consider myself an amateur electrician, plumber, and carpenter. Some of the projects are actually up to code, not all. But you get to learn how other people have lived their lives and how they made things. And that could be making something concrete, like an addition to their house, or it can be making a life. Megan Dupuis: Yeah, I love that you say that it is selfish, and we acknowledge that. You know, sometimes I think that we went into internal medicine and ultimately oncology... and I don't mean this in a trite way: I want the gossip about your life. I want the details. I want to dig into your hobbies, your relationships, what makes you angry, what makes you excited. I think they're the fun things to learn about folks. Again, in some ways, I think the cancer diagnosis is almost such a trite or banal part of who a human is. It's not to say that it's not going to shape their life in a very profound way, but it's not something they picked. It's something that happened to them. And so I'm much more excited to say, “Hey, what are your weekend hobbies? Are you an amateur electrician?” And that dovetails deeply into what kind of treatment might help you to do those things for longer. So I think it is a little bit selfish that it gives me a lot of satisfaction to get to know who people are. Mikkael Sekeres: So part of what we're talking about, indirectly, is the sense of otherness. And an undercurrent theme in your essay is otherness. You were an 'other' as a fellow in training and working in Texas when you grew up in upstate New York. And our patients are also 'others.' They're thrust into this often complicated bedlam of cancer care. Can you talk about how you felt as an 'other' and how that's affected your approach to your patients? Megan Dupuis: I think in the cancer experience, we are 'other,' definitionally, from the start, for exactly the reasons that you said. I'm coming to it as your physician; you're coming to it as my patient. This is a new encounter and a new experience for both of us. I think the added layer of being this person from upstate New York who didn't... I mean, I minored in Spanish in college, but that's not the same thing as growing up in a culture that speaks Spanish, that comes from a Spanish-speaking country—the food, the culture. It's all incredibly different. And so the way that I approached it there was to say, “I am genuinely curious. I want to know what it's like to be different than the culture that I was raised in.” And I'm excited to know about that thing.   And I think we can tell—I think, as humans—when somebody is genuinely curious about who you are and what's important to you, versus when they're kind of just checking the boxes to try to build a relationship that's necessary. I think my patients could tell that even though I'm not necessarily speaking their language, I want to know. I ask these questions because I want to know. I think if you go to it from a place of curiosity, if you are approaching another person with a genuine sense of curiosity... You know, Faith Fitzgerald wrote her most remarkable piece on curiosity many, many years ago. But even the quote-unquote “boring” patient, as she put it, can have an incredible story to tell if you're curious enough to ask. And so I think that no matter how different I might be culturally from the patient sitting across from me, if I approach it with a genuine sense of curiosity, and they can sense that, that. that's going to build the bond that we need truly to walk together on this cancer journey. I think it's curiosity, and I think it's also sharing of yourself. I think that nobody is going to open up to you if they feel that you are closed to sharing a bit of yourself. Patients want to know who their doctor is, too. So when I said I asked those five or six minutes' worth of questions at the beginning of a new patient encounter, I share that info with them. I tell them where I live, how long it takes for me to get to clinic, who my people are, the name of my dog, what I like to do in my spare time, what I'm proud of. So I share that with them too, so it doesn't feel like a one-way grilling. It feels like an introduction, a meeting, the start of a... I don't want to say friendship necessarily, but a start of a friendliness, of a shared communal experience. Mikkael Sekeres: Well, it's a start of a relationship. And you can define 'relationship' with a broad swath of definitions, right? Megan Dupuis: That's right. Mikkael Sekeres: It can be a relationship that is a friendship. It can be a relationship that's a professional relationship. And just like we know some personal things about some of our colleagues, the same is true of our patients. I was wondering if I could pick up on... I love that notion of curiosity that you brought out because that's something I've thought a lot about, and I've thought about whether it could be at least one way to combat burnout. So could you put that in context of burnout? Do you think maintaining that curiosity throughout a career is one potential solution to burnout? And do you think that being open with yourself also helps combat burnout, which is counterintuitive to what we've always been taught? Megan Dupuis: Wow. I think that this is such an important question, and it's almost like you read my justification for a Medical Humanities Certificate Program. One of the foundational arguments for why I thought the GME should support the creation of this program at Vanderbilt was because we hypothesized that it would improve burnout. And one of the arms of that is because it engenders a sense of genuine curiosity. When you're thinking about the arms of burnout: it's loss of meaning in your work; it's depersonalization of patients, right, when they're treated as objects or numbers or a ticket in the system that you have to shuffle through; when it's disconnection from the work that you do. I absolutely think that curiosity is an antidote to burnout. I don't think it's the whole solution, perhaps, because I think that burnout also includes systemic injury and structures of our medical healthcare system that no individual can fix in a vacuum. But I do think when we're thinking about what are the changes that we as individual physicians can make, I do think that being open and curious about your patient is one of the best salves that we have against some of these wounds. You know, I've never left a room where a patient has shared a personal story and felt worse about it, right? I've always felt better for the experience. And so I do think curiosity is an incredibly important piece of it. It's hard, I will acknowledge. It's hard for the speed that we move through the system, the pace that we move through the system. And I'm thinking often about my trainees—my residents, my fellows—who are seeing a lot, they're doing a lot, they are trying to learn and drink from the fire hose of the pace of medical development, checking so many boxes. And so to remain curious, I think at times can feel like a luxury. I think it's a luxury I have boomeranged back into as an attending. You know, certainly as a resident and a fellow, I felt like, “Gosh, why does this attending want to sit and chitchat about this person's music career? I'm just trying to make sure their pain is controlled. I'm trying to make sure they get admitted safely. I'm trying to make sure that they're getting the right treatment.” And I think it's something that I've tried to teach my trainees: “No, we have the time. I promise we have the time to ask this person what their childhood was like,” if that's something that is important to the narrative of their story. So it sometimes feels like a luxury. But I also think it's such a critical part of avoiding or mitigating the burnout that I know all of us face. Mikkael Sekeres: I think you touched on a lot of really important points. Burnout is so much more complicated than just one inciting factor and one solution. It's systemic. And I love also how you positioned curiosity as a bit of a luxury. We have to have the mental space to also be curious and engaged enough in our work that we can take interest in other people. I wanted to touch on one more question. You write in your essay that a patient in pajamas is a canary in the coal mine for deteriorating health. And I completely, completely agree with that. I can vividly recall a number of patients where I saw them in my clinic, and I would look down, and they had food spilled on their sweatshirt, or they were wearing mismatched socks, or their shoes weren't tied. And you thought to yourself, “Gee, this person is not thriving at home.” Do you think telemedicine has affected our ability to recognize that in our patients? Megan Dupuis: Yes, I do think so. I can remember vividly being a fellow when COVID first began in 2020, and I was training in an environment where most of my patients spoke Spanish or Vietnamese. And so we were doing not just telemedicine; we were doing telephone call clearance for chemotherapy because a lot of the patients didn't have either access to the technology or a phone that had video capability. A lot of them had flip phones. And trying to clear somebody for chemotherapy over the phone, I'll tell you, Mikkael, was the number one way to lead to a recipe of moral injury and burnout. As a person who felt this deep responsibility to do something safe... I think even now with telemedicine, there are a lot of things that you can hide from the waist down, right? If you can get it together enough to maybe just put a shirt on, I won't know that you're sitting there in pajama bottoms. I won't know that you're struggling to stand or that you're using an assistive device to move when you used to be able to come into clinic without one, or that your family member is helping you negotiate stepping over the curb in clinic. These are real litmus tests that you and I, all of us, use when we're deciding whether somebody is safe to receive a treatment. And I think telemedicine does mask some of that. Now, on the other hand, does telemedicine provide an access point for patients that otherwise it would be a challenge to drive into clinic for routine visits and care? It does, and I think it's been an incredible boon for patients who live far away from the clinic. But I think we have to use it judiciously. And there are patients where I will say, “If you are not well enough to get yourself to clinic, I worry that you are not well enough to safely receive treatment.” And when I'm thinking about the rules of chemo, it's three: It has to be effective, right? Cancer decides that. It has to be something the patient wants. They decide. But then the safety piece—that's my choice. That's my responsibility. And I can't always decide safety on a telemedicine call. Mikkael Sekeres: I completely agree. I've said to my patients before, “It's hard for me to assess you when I'm only seeing 40% of you.” So we will often negotiate them having to withstand the traffic in Miami to come in so I can feel safe in administering the chemotherapy that I think they need. Megan Dupuis: That's exactly right. Mikkael Sekeres: Megan Dupuis, it has been an absolute delight getting to chat with you. It has been just terrific getting to know you and talk about your fabulous essay, "Tamales." So thank you so much for joining me. Megan Dupuis: Thank you for having me. It was a wonderful time to chat with you as well. Mikkael Sekeres: Until next time, thank you for listening to JCO's Cancer Stories: The Art of Oncology. Don't forget to give us a rating or review, and be sure to subscribe so you never miss an episode. You can find all of ASCO's shows at asco.org/podcasts. Thank you again.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.  Like, share and subscribe so you never miss an episode and leave a rating or review. Guest Bio: Dr Megan Dupuis is an Assistant Professor of Hematology and Oncology at Vanderbilt University Medical Center.  

In this episode of Integrative Oncology Talk, host Judith Lacey welcomes Dr. Santhosshi Narayanan from MD Anderson to discuss Ayurvedic medicine's potential benefits for cancer patients. Narayan, an internal medicine physician specializing in integrative oncology, delves into the ancient practices of Ayurveda, which emphasizes a personalized approach incorporating diet, exercise, and mind-body techniques. The conversation covers Ayurveda's principles, how it can complement conventional cancer care, and the importance of studying Ayurvedic herbs for safety and efficacy. The episode also discusses the significance of collaboration between conventional and Ayurvedic practitioners to provide comprehensive, patient-tailored cancer care.

Rev. Jodi of Self-Cell Care, Suson Essentials, welcomes Ryan Encinas, a holistic RN, specializes in metabolic health and mindset optimization. Utilizing Nobel Prize-winning Physics, the Bio Scanner, he teaches cellular antioxidant metrics to address nutrient deficiencies. Ryan collaborates with diverse health practitioners to promote prevention and measurable nutrient optimization. With a background in Cancer Surgery at MD Anderson, his experience spans surgical assistance, directorial roles, and Bio Chem, Cell Function, Genetics, and Spirituality. He emphasizes personalized nutrition, lifestyle modifications, and stress management with radical ownership to enhance health span. " We are a system, not symptoms."  All Dis-ease boil down to 2 things. 1. deficiency 2. toxicity Guest: Ryan Encinas, ryan@my-holistic-hub.com , https://holistichub.gethealthyusa.com..., * IG:   / _holistic_hub   FB:   / 18akl2uoom   in:   / ryan-encinas-holistihub   Host: Rev. Jodi Suson Jodi@SusonEssentials.com ; www.susonessentials.com, YouTube    / @susonessentials   Facebook   / susonessentials   Twitter   / susonessentials   Instagram    / susonessentials    

RUSH MD Anderson Cancer Center's Breast Cancer Risk Assessment and Personalized Screening Program incorporates sophisticated diagnostic and therapeutic tools that Lisa Stempel, MD, and her colleagues use to determine the most effective care pathway for patients who are at high risk for breast cancer. Dr. Stempel is a diagnostic radiologist at RUSH MD Anderson. She is chief of the Division of Breast Imaging and director of the High-Risk Cancer Screening Program at RUSH MD Anderson. “Screening mammography is a great model we can use for early detection for other types of cancers. For example, if we can catch breast cancer in its early stages, say stage 0 or 1, there's a 99.9% cure rate. Even if it's stage 2, we have a 93% cure rate. Early detection applies to almost all types of cancers, too. What we've learned is that with mammography and the addition of supplemental screening tests, we can find breast cancer at the earliest stages.”  

Dr. Ebony Hoskins and Dr. Andreas Obermair discuss the surgical management of gynecologic cancers, including the role of minimally invasive surgery, approaches in fertility preservation, and the nuances of surgical debulking. TRANSCRIPT Dr. Ebony Hoskins: Hello and welcome to the ASCO Daily News Podcast, I'm Dr. Ebony Hoskins. I'm a gynecologic oncologist at MedStar Washington Hospital Center in Washington, DC, and your guest host of the ASCO Daily News Podcast. Today we'll be discussing the surgical management of gynecologic cancer, including the role of minimally invasive surgery (MIS), approaches in fertility preservation, and the nuances of surgical debulking, timing, and its impact on outcomes. I am delighted to welcome Dr. Andreas Obermair for today's discussion. Dr. Obermair is an internationally renowned gynecologic oncologist, a professor of gynecologic oncology at the University of Queensland, and the head of the Queensland Center for Gynecologic Cancer Research. Our full disclosures are available in the transcript of this episode. Dr. Obermair, it's great speaking with you today. Dr. Andreas Obermair: Thank you so much for inviting me to this podcast. Dr. Ebony Hoskins: I am very excited.  I looked at your paper and I thought, gosh, is everything surgical? This is everything that I deal with daily in terms of cancer in counseling patients. What prompted this review regarding GYN cancer management? Dr. Andreas Obermair: Yes, our article was published in the ASCO Educational Book; it is volume 44 in 2024. And this article covers some key aspects of targeted precision surgical management principles in endometrial cancer, cervical cancer, and ovarian cancer. While surgery is considered the cornerstone of gynecologic cancer treatment, sometimes research doesn't necessarily reflect that. And so I think ASCO asked us to; so it was not just me, there was a team of colleagues from different parts of the United States and Australia to reflect on surgical aspects of gynecologic cancer care and I feel super passionate about that because I do believe that surgery has a lot to offer. Surgical interventions need to be defined and overall, I see the research that I'm doing as part of my daily job to go towards precision surgery. And I think that is, well, that is something that I'm increasingly passionate for. Dr. Ebony Hoskins: Well, I think we should get into it. One thing that comes to mind is the innovation of minimally invasive surgery in endometrial cancer. I always reflect on when I started my fellowship, I guess it's been about 15 years ago, all of our endometrial cancer patients had a midline vertical incision, increased risk of abscess, infections and a long hospital stay. Do you mind commenting on how you see management of endometrial cancer today? Dr. Andreas Obermair: Thank you very much for giving the historical perspective because the generation of gynecologic oncologists today, they may not even know what we dealt with, what problems we had to solve. So like you, when I was a fellow in gynecologic oncology, we did midline or lower crosswise incisions, the length of stay was, five days, seven days, but we had patients in hospital because of complications for 28 days. We took them back to the operating theaters because those are patients with a BMI of 40 plus, 45, 50 and so forth. So we really needed to solve problems. And then I was exposed to a mentor who taught minimal invasive surgery. And in Australia he was one of the first ones who embarked on that. And I can remember, I was mesmerized by this operation, like not only how logical this procedure was, but also we did rounds afterwards. And I saw these women after surgery and I saw them sitting upright, lipstick on, having had a full meal at the end of the day. And I thought, wow, this is the most rewarding experience that I have to round these patients after surgery. And so I was thinking, how could I help to establish this operation as standard? Like a standard that other people would accept this is better. And so I thought we needed to do a trial on this. And then it took a long time. It took a long time to get the support for the [LACE - Laparoscopic Approach to Cancer of the Endometrium] trial. And in this context, I just also wanted to remind us all that there were concerns about minimal invasive surgery in endometrial cancer at the time. So for example, one of the concerns was when I submitted my grant funding applications, people said, “Well, even if we fund you, wouldn't be able to do this trial because there are actually no surgeons who actually do minimally invasive surgery.” And at the time, for example, in Australia, there were maybe five people, a handful of people who were able to do this operation, right? This was about 20 years ago. The other concern people had was they were saying, could minimally invasive surgery for endometrial cancer, could that cause port side metastasis because there were case reports. So there were a lot of things that we didn't know anyway. We did this trial and I'm super happy we did this trial. We started in 2005, and it took five years to enroll. At the same time, GOG LAP2 was ramping up and the LACE trial and GOG LAP2 then got published and provided the foundations for minimally invasive surgery in endometrial cancer. I'm super happy that we have randomized data about that because now when we go back and now when people have concerns about this, should we do minimally invasive surgery in P53 mutant tumors, I'm saying, well, we actually have data on that. We could go back, we could actually do more research on that if we wanted to, but our treatment recommendations are standing on solid feet. Dr. Ebony Hoskins: Well, my patients are thankful. I see patients all the time and they have high risk and morbidly obese, lots of medical issues and actually I send them home most the same day. And I think, you know, I'm very appreciative of that research, because we obviously practice evidence-based and it's certainly a game changer. Let's go along the lines of MIS and cervical cancer. And this is going back to the LACC [Laparoscopic Approach to Cervical Cancer] trial.  I remember, again, one of these early adopters of use of robotic surgery and laparoscopic surgery for radical hysterectomy and thought it was so cool. You know, we can see all the anatomy well and then have the data to show that we actually had a decreased survival. And I even see that most recent updated data just showing it still continued. Can you talk a little bit about why you think there is a difference? I know there's ongoing trials, but still interested in kind of why do you think there's a survival difference? Dr. Andreas Obermair:  So Ebony, I hope you don't mind me going back a step. So the LACC study was developed from the LACE trial. So we thought we wanted to reproduce the LACE data/LAP2 data. We wanted to reproduce that in cervix cancer. And people were saying, why do you do that? Like, why would that be different in any way? We recognize that minimally invasive radical hysterectomy is not a standard. We're not going to enroll patients in a randomized trial where we open and do a laparotomy on half the patients. So I think the lesson that really needs to be learned here is that any surgical intervention that we do, we should put on good evidence footing because otherwise we're really running the risk of jeopardizing patients' outcomes. So, that was number one and LACC started two years after LACE started. So LACC started in 2007, and I just wanted to acknowledge the LACC principal investigator, Dr. Pedro Ramirez, who at the time worked at MD Anderson. And we incidentally realized that we had a common interest. The findings came totally unexpected and came as an utter shock to both of us. We did not expect this. We expected to see very similar disease-free and overall survival data as we saw in the endometrial cancer cohort. Now LACC was not designed to check why there was a difference in disease-free survival. So this is very important to understand. We did not expect it. Like, so there was no point checking why that is the case. My personal idea, and I think it is fair enough if we share personal ideas, and this is not even a hypothesis I want to say, this is just a personal idea is that in endometrial cancer, we're dealing with a tumor where most of the time the cancer is surrounded by a myometrial shell. And most of the time the cancer would not get into outside contact with the peritoneal cavity. Whereas in cervix cancer, this is very different because in cervix cancer, we need to manipulate the cervix and the tumor is right at the outside there. So I personally don't use a uterine manipulator. I believe in the United States, uterine manipulators are used all the time. My experience is not in this area, so I can't comment on that. But I would think that the manipulation of the cervix and the contact of the cervix to the free peritoneal cavity could be one of the reasons. But again, this is simply a personal opinion. Dr. Ebony Hoskins: Well, I appreciate it. Dr. Andreas Obermair: Ebony at the end of the day, right, medicine is empirical science, and empirical science means that we just make observations, we make observations, we measure them, and we pass them on. And we made an observation. And, and while we're saying that, and yes, you're absolutely right, the final [LACC] reports were published in JCO recently. And I'm very grateful to the JCO editorial team that they accepted the paper, and they communicated the results because this is obviously very important. At the same time, I would like to say that there are now three or four RCTs that challenge the LACC data. These RCTs are ongoing, and a lot of people will be looking forward to having these results available. Dr. Ebony Hoskins: Very good. In early-stage cervical cancer, the SHAPE trial looked at simple versus radical hysterectomy in low-risk cervical cancer patients. And as well all know, simple hysterectomy was not inferior to radical hysterectomy with respect to the pelvic recurrence rate and any complications related to surgery such as urinary incontinence and retention. My question for you is have you changed your practice in early-stage cervical cancer, say a patient with stage 1B1 adenocarcinoma with a positive margin on conization, would you still offer this patient a radical hysterectomy or would you consider a simple hysterectomy? Dr. Andreas Obermair:  I think this is a very important topic, right? Because I think the challenge of SHAPE is to understand the inclusion criteria. That's the main challenge. And most people simplify it to 2 cm, which is one of the inclusion criteria but there are two others and that includes the depth of invasion. Dr. Marie Plante has been very clear. Marie Plante is the first author of the SHAPE trial that's been published in the New England Journal of Medicine only recently and Marie has been very clear upfront that we need to consider all three inclusion criteria and only then the inclusion criteria of SHAPE apply. So at the end of the day, I think what the SHAPE trial is telling us that small tumors that would strictly fulfill the criteria of a 1B or 1B1 cancer of the cervix can be considered for a standard type 1 or PIVA type 1 or whatever classification we're trying to use will be eligible. And that makes a lot of sense. I personally not only look at the size, I also look at the location of the tumor. I would be very keen that I avoid going through tumor tissue because for example, if you have a tumor that is, you know, located very much in one corner of the cervix and then you do a standard hysterectomy and then you have a positive tumor margin that would be obviously, most people would agree it would be an unwanted outcome. So I'd be very keen checking the location, the size of the tumor, the depths of invasion and maybe then if the tumor for example is on one side of the cervix you can do a standard approach on the contralateral side but maybe do a little bit more of a margin, a parametrial margin on the other side. Or if a tumor is maybe on the posterior cervical lip, then you don't need to worry so much about the anterior cervical margin, maybe take the rectum down and maybe try to get a little bit of a vaginal margin and the margin on the uterus saccals. Just really to make sure that you do have margins because typically if we get it right, survival outcomes of clinical stage 1 early cervix cancer 1B1 1B 2 are actually really good. It is a very important thing that we get the treatment right. In my practice, I use a software to record my treatment outcomes and my margins. And I would encourage all colleagues to be cognizant and to be responsible and accountable to introduce accountable clinical practice, to check on the margins and check on the number on the percentage of patients who require postoperative radiation treatment or chemo radiation. Dr. Ebony Hoskins: Very good. I have so many questions for you. I don't know the statistics in Australia, but here, there's increased rising of endometrial cancer and certainly we're seeing it in younger women. And fertility always comes up in terms of kind of what to do. And I look at the guidelines and, see if I can help some of the women if they have early-stage endometrial cancer. Your thoughts on what your practice is on use of someone who may meet criteria, if you will. The criteria I use is grade 1 endometrioid adenocarcinoma. No myometria invasion. I try to get MRI'd and make sure that there's no disease outside the endometrium. And then if they make criteria, I typically would do an IUD. Can you tell me what your practice is and where you've had success? Dr. Andreas Obermair: So, we initiated the feMMe clinical trial that was published in 2021 and it was presented in a Plenary at one of the SGO meetings. I think it was in 2021, and we've shown complete pathological response rates after levonorgestrel intrauterine device treatment. And so in brief, we enrolled patients with endometrial hyperplasia with atypia, but also patients with grade 1 endometrial adenocarcinoma. Patients with endometrial hyperplasia with atypia had, in our series, had an 85 % chance of developing a complete pathological response. And that was defined as the complete absence of any atypia or cancer. So endometrial hyperplasia with atypia responded in about 85%. In endometrial cancer, it was about half, it was about 45, 50%. In my clinical practice, like as you, I see patients, you know, five days a week. So I'm looking after many patients who are now five years down from conservative treatment of endometrial cancer. There are a lot of young women who want to get pregnant, and we had babies, and we celebrate the babies obviously because as gynecologist obstetricians it couldn't get better than that, right, if our cancer patients have babies afterwards. But we're also treating women who are really unfit for surgery and who are frail and where a laparoscopic hysterectomy would be unsafe. So this phase is concluded, and I think that was very successful. At least we're looking to validate our data. So we're having collaborations, we're having collaborations in the United States and outside the United States to validate these data. And the next phase is obviously to identify predictive factors, to identify predictors of response. Because as you can imagine, there is no point treating patients with a levonorgestrel intrauterine joint device where we know in advance that she's not going to respond. So this is a very, very fascinating story and we got our first set of data already, but now we just really need to validate this data. And then once the validation is done, my unit is keen to do a prospective validation trial. And that also needs to involve international collaborators. Dr. Ebony Hoskins: Very good. Moving on to ovarian cancer, we see patients with ovarian cancer with, say, at least stage 3C or higher who started neoadjuvant chemotherapy. Now, some of these patients are hearing different things from their medical oncologist versus their gynecologic oncologist regarding the number of cycles of neoadjuvant chemotherapy after getting diagnosed with ovarian cancer. I know that this can be confusing for our patients coming from a medical oncologist versus a gynecologic oncologist. What do you say to a patient who is asking about the ideal number of chemotherapy cycles prior to surgery? Dr. Andreas Obermair: So this is obviously a very, very important topic to talk about. We won't be able to provide a simple off the shelf answer for that, but I think data are emerging.  The ASCO guidelines should also be worthwhile considering because there are actually new ASCO Guidelines [on neoadjuvant chemotherapy for newly diagnosed, advanced ovarian cancer] that just came out a few weeks ago and they would suggest that we should be aiming for R0 in surgery. If we can maybe take that as the pivot point and then go back and say, okay, so what do need to do to get the patient to zero?  I'm not an ovarian cancer researcher; I'm obviously a practicing gynecologic oncologist. I think about things a lot and things like that. In my practice, I would want a patient to develop a response after neoadjuvant chemotherapy. So, if a patient doesn't have a response after two or three cycles, then I don't see the point for me to offer her an operation. In my circle with the medical oncologists that I work with, I have a very, very good understanding. So, they send the patient to me, I take them to the theater. I take a good chunk of tissue from the peritoneum. We have a histopathologic diagnosis, we have a genomic diagnosis, they go home the same day. So obviously there is no hospital stay involved with that. They can start the chemotherapy after a few days. There is no hold up because the chances of surgical complication in a setting like this is very, very low. So I use laparoscopy to determine whether the patient responds or not. And for many of my patients, it seems to work. It's obviously a bit of an effort and it takes operating time. But I think I'm increasing my chances to make the right decision. So, coming back to your question about whether we should give three or six cycles, I think the current recommendations are three cycles pending the patient's response to neoadjuvant chemotherapy because my aim is to get a patient to R0 or at least minimal residual disease. Surgery is really, in this case, I think surgery is the adjunct to systemic treatment. Dr. Ebony Hoskins: Definitely. I think you make a great point, and I think the guideline just came out, like you mentioned, regarding neoadjuvant. And I think the biggest thing that we need to come across is the involvement of a gynecologic oncologist in patients with ovarian cancer. And we know that that survival increases with that involvement. And I think the involvement is the surgery, right? So, maybe we've gotten away from the primary tumor debulking and now using more neoadjuvant, but surgery is still needed. And so, I definitely want to have a take home that GYN oncology is involved in the care of these patients upfront. Dr. Andreas Obermair: I totally support that. This is a very important statement. So when I'm saying surgery is the adjunct to medical treatment, I don't mean that surgery is not important. Surgery is very important. And the timing is important. And that means that the surgeons and the med oncs need to be pulling on the same string. The med oncs just want to get the cytotoxic into the patients, but that's not the point, right? We want to get the cytotoxic into the patients at the right time because if we are working under this precision surgery, precision treatment mantra, it's not only important what we do, but also doing it at the right time. And ideally, I I would like to give surgery after three cycles of neoadjuvant chemotherapy, if that makes sense. But sometimes for me as a surgeon, I talk to my med onc colleagues and I say, “Look, she doesn't have a good enough response to her treatment and I want her to receive six cycles and then we re-evaluate or change medical treatment,” because that's an alternative that we can swap out drugs and treat upfront with a different drug and then sometimes they do respond. Dr. Ebony Hoskins:  I have maybe one more topic. In the area I'm in, in the Washington D.C. area, we see lots of endometrial cancer and they're not grade 1, right? They're high-risk endometrial cancer and advanced. So a number of patients with stage 3 disease, some just kind of based off staging and then some who come in with disease based off of the CT scan, sometimes omental caking, ascites. And the real question is we have extrapolated the use of neoadjuvant chemotherapy to endometrial cancer. It's similar, but not the same. So my question is in an advanced endometrial cancer, do you think there's still a role, when I say advanced, I mean, maybe stage 4, a role for surgery? Dr. Andreas Obermair: Most definitely. But the question is when do you want to give this surgery? Similar to ovarian cancer, in my experience, I want to get to R0. What am I trying to achieve here? So, I reckon we should do a trial on this. And I reckon we have, as you say, the number of patients in this setting is increasing, we could do a trial. I think if we collaborate, we would have enough patients to do a proper trial. Obviously, we would start maybe with a feasibility trial and things like that. But I reckon a trial would be needed in this setting because I find that the incidence that you described, that other people would come across, they're becoming more and more common. I totally agree with you, and we have very little data on that. Dr. Ebony Hoskins: Very little and we're doing what we can. Dr. Obermair, thank you for sharing your fantastic insights with us today on the ASCO Daily News Podcast and for all the work you do to advance care for patients with gynecologic cancer. Dr. Andreas Obermair: Thank you, Dr. Hoskins, for hosting this and it's been an absolute pleasure speaking with you today. Dr. Ebony Hoskins: Definitely a pleasure and thank you to our listeners for your time today. Again, Dr. Obermair's article is titled, “Controversies in the Surgical Management of Gynecologic Cancer: Balancing the Decision to Operate or Hesitate,” and was published in the 2024 ASCO Educational Book. And you'll find a link to the article in the transcript of this episode. Finally, if you value the insights that you hear on the ASCO Daily News Podcast, please take a moment to rate, review and subscribe wherever you get your podcasts. Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement. Find out more about today's speakers: Dr. Ebony Hoskins @drebonyhoskins Dr. Andreas Obermair @andreasobermair Follow ASCO on social media:       @ASCO on Twitter       ASCO on Bluesky   ASCO on Facebook       ASCO on LinkedIn       Disclosures:   Dr. Ebony Hoskins: No relationships to disclose. Dr. Andreas Obermair: Leadership: SurgicalPerformance Pty Ltd. Stock and Ownership Interests: SurgicalPerformance Pty Ltd. Honoraria: Baxter Healthcare Consulting or Advisory Role: Stryker/Novadaq Patents, Royalties, and Other Intellectual Property: Shares in SurgicalPerformance Pty Ltd. Travel, Accommodation, Expenses: Stryker    

Dr Akila Viswanathan speaks with Dr Robert Coppes from The University Medical Center Groningen, Dr David Jaffray from MD Anderson Cancer Center and Dr Helen McNair from The Royal Marsden NHS Foundation Trust Institute of Cancer Research to look ahead to the future of radiation oncology as they discuss how to improve decision making, incorporating artificial intelligence, adapt to new training methods, improve safety and sustainability and much more for Seminars in Radiation Oncology.

Join the Behind the Knife Surgical Oncology Team as we discuss the presentation, work-up, and management of neuroendocrine tumors of the small bowel. Learning Objectives: In this episode, we review the basics of neuroendocrine (NE) tumors of the small bowel, including how to evaluate patients with presenting symptoms consistent with NE tumors, initial work-up, staging, and management.  We discuss key concepts including DOTATATE scans and medical therapies high yield for direct patient care and board exams.  Hosts: Timothy Vreeland, MD, FACS (@vreelant) is an Assistant Professor of Surgery at the Uniformed Services University of the Health Sciences and Surgical Oncologist at Brooke Army Medical Center Daniel Nelson, DO, FACS (@usarmydoc24) is Surgical Oncologist/HPB surgeon at Kaiser LAMC in Los Angeles. Connor Chick, MD (@connor_chick) is a 2nd Year Surgical Oncology fellow at Ohio State University. Lexy (Alexandra) Adams, MD, MPH (@lexyadams16) is a 1st Year Surgical Oncology fellow at MD Anderson. Beth (Elizabeth) Barbera, MD (@elizcarpenter16) is a PGY-6 General Surgery resident at Brooke Army Medical Center Links to Paper Referenced in this Episode: Strosberg J, El-Haddad G, Wolin E, Hendifar A, Yao J, Chasen B, Mittra E, Kunz PL, Kulke MH, Jacene H, Bushnell D, O'Dorisio TM, Baum RP, Kulkarni HR, Caplin M, Lebtahi R, Hobday T, Delpassand E, Van Cutsem E, Benson A, Srirajaskanthan R, Pavel M, Mora J, Berlin J, Grande E, Reed N, Seregni E, Öberg K, Lopera Sierra M, Santoro P, Thevenet T, Erion JL, Ruszniewski P, Kwekkeboom D, Krenning E; NETTER-1 Trial Investigators. Phase 3 Trial of 177Lu-Dotatate for Midgut Neuroendocrine Tumors. N Engl J Med. 2017 Jan 12;376(2):125-135. doi: 10.1056/NEJMoa1607427. PMID: 28076709; PMCID: PMC5895095. https://pubmed.ncbi.nlm.nih.gov/28076709/ ***SPECIALTY TEAM APPLICATION LINK: https://docs.google.com/forms/d/e/1FAIpQLSdX2a_zsiyaz-NwxKuUUa5cUFolWhOw3945ZRFoRcJR1wjZ4w/viewform?usp=sharing Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

In this episode, we discuss the management of CML with Dr. Hagop Kantarjian from MD Anderson Cancer Center. Here are the key articles we discussed:  1. ASC4FIRST RCT: Asciminib in newly diagnosed CML. https://pubmed.ncbi.nlm.nih.gov/38820078/ 2. 5-year follow-up of ENESTnd RCT (nilotinib): https://pubmed.ncbi.nlm.nih.gov/26837842/ 3. 10-year follow-up of ENESTnd RCT (nilotinib): https://pubmed.ncbi.nlm.nih.gov/33414482/ 4. 10-year follow-up of CML-IV RCT (imatinib): https://pubmed.ncbi.nlm.nih.gov/25676422/ 5. MD Anderson data on low-dose dasatinib (50 mg): https://pubmed.ncbi.nlm.nih.gov/36054032/https://pubmed.ncbi.nlm.nih.gov/31553487/ 6. CML: 2025 update on diagnosis, therapy, and monitoring: https://pubmed.ncbi.nlm.nih.gov/39093014/ 

Dr. Shaalan Beg and Dr. David Wang discuss key abstracts in GI cancers from the 2025 ASCO Gastrointestinal Cancers Symposium, including major advances in CRC, neoadjuvant approaches in esophageal cancer, and innovative studies on ctDNA. TRANSCRIPT Dr. Shaalan Beg: Hello and welcome to the ASCO Daily News Podcast. I'm Dr. Shaalan Beg. I'm a medical oncologist and an adjunct associate professor at UT Southwestern Medical Center in Dallas. Today, we're bringing you some key highlights from the 2025 ASCO Gastrointestinal Cancers Symposium, and I'm delighted to be joined by the chair of GI25, Dr. David Wang. Dr. Wang is a GI medical oncologist at the University of Michigan. Our full disclosures are available in the transcript of this episode.  Dr. Wang, thanks for coming on the podcast today. Dr. David Wang: Well, thank you. It's a pleasure to be here. Dr. Shaalan Beg: GI25 featured major therapeutic advances across the spectrum of GI malignancies, and it was exciting to hear about innovations and novel approaches that are shaping the future of our field. Before we start talking about specific abstracts, could you share some of your key highlights from the meeting? Dr. David Wang: Sure. Our theme this year was “Breaking Boundaries to Enhance Patient Centered Care.” Past years' themes have focused more on precision oncology, but we wanted to broaden our focus on patients and to be more holistic, which kind of led us into some of the Intersection [sessions] that we had. Each day started with a different Intersection. The first one was “Emerging Therapies in GI Cancers”, where invited speakers talked about bispecific antibody drug conjugates, theranostics, CAR T and other cell-based therapies. The second day was on “Personalized Risk Assessment for GI Cancers,” and this included looking at polygenic risk scores for colorectal cancer, microRNAs and liquid biopsies such as exosomes and pancreatic cancer and non-endoscopic screening modalities in esophageal cancer. And on our final day, we wanted to talk about “Integrative Oncology and Integrative Medicine,” looking at evidence-based uses of acupuncture and supplements in patients who are receiving treatment for cancer, mindfulness-based practices and exercise. And of course, we had a fantastic keynote talk by Dr. Pamela Kunz from the Yale School of Medicine titled, “Disrupting Gastrointestinal Oncology: Shattering Barriers with Inclusive Science.” She highlighted the intersection of science, patient care, and health and gender equity. And I would encourage your podcast listeners to access the lecture in ASCO's Meeting Library if they haven't yet had a chance to hear Dr. Kunz's wonderful lecture.  We were really happy this year because the attendance hit a new record. We had over 5,000 people attend either in person or virtually from their home or office, and we had almost 1,000 abstracts submitted to the meeting, so these were either record or near record numbers. We offered a lot of different networking opportunities throughout the meeting, and attending found these to be incredibly rewarding and important and this will continue to be an area of emphasis in future meetings. Dr. Shaalan Beg: Let's take a deeper dive into the exciting studies presented at GI25. The late breaking abstract LBA143 was CheckMate-8HW. This was the first results of NIVO + IPI versus NIVO monotherapy for MSI-high metastatic colorectal cancer. What are your thoughts about this study? Dr. David Wang: Yeah, so we know that colorectal cancer patients with MSI-high tumors don't necessarily respond well to chemotherapy. And we were fortunate because last year CheckMate-8HW actually looked at two different arms – so this was NIVO + IPI compared to standard of care chemotherapy and showed its very significant improvement in median progression-free survival. And that was actually published in the New England Journal of Medicine back in November of 2024. This year's presentation actually focused now on NIVO + IPI versus NIVO monotherapy. And as you know IPI+NIVO can be quite toxic. So this was an important analysis to be done. So we know that NIVO is definitely more easily tolerated. So what was interesting was that the 2-year and 3-year progression-free survival not surprisingly favored IPI+NIVO and this was statistically significant. And the overall response rate was also better with IPI+NIVO versus NIVO alone. I know we're always concerned about toxicities and there were higher grade 3 and 4 toxicity incidences in the combination arm versus the monotherapy arm, but overall, only about 28 additional events in several hundred patients treated. So I think that's well-tolerated. Our discussant Dr. Wells Messersmith actually said that, with this new data, he would consider doing combination immunotherapy in any patient that presented in the front line with MSI-high or deficient mismatch repair colorectal cancer that was metastatic. Dr. Shaalan Beg: One of the focuses for directing first-line therapy for colorectal cancer has been right and left sided colon cancer because we know these are two different cancers with their own unique molecular subtypes. We heard on Abstract 17, the DEEPER trial, the final analysis of modified FOLFOXIRI plus cetuximab versus bevacizumab for RAS wild-type and left sided metastatic colorectal cancer. How do you summarize the findings of this study and what should our readers be aware of? Dr. David Wang: Interestingly, this was a phase 2 study and the emphasis of the abstract was actually a subgroup analysis of those patients with RAS wild-type and BRAF wild-type as well as left sided cancers. So, I think the entire study enrolled 359 patients, but the analysis that was discussed at the meeting really focused on 178 patients that fit that characteristic. Very similar to what we've seen in prior studies, left-sided tumors have better response to cetuximab versus bevacizumab. And if you flip it so that you now are looking at right sided tumors, targeting EGFR is actually detrimental. The depth of response was better with cetuximab in these left sided RAS and BRAF mutant tumors. And so the lead author actually suggested that this could be a new first-line standard of care. And the question is, is there a benefit of doing this triple agent regimen with modified FOLFIRINOX? We know there's a lot more toxicity with that. Not clear that there's a benefit for that over FOLFOX, maybe in younger patients that could tolerate it. When our discussant, again Dr. Wells Messersmith, spoke about this, he said that, in his practice he would, again, favor cetuximab over bevacizumab in combination with chemo, these left-sided RAS and BRAF wild-type tumors, but that he would actually prefer a doublet versus a triplet chemo regimen, and that is consistent with the current NCCN guidelines. Dr. Shaalan Beg: Another area where colorectal cancer has been a wonderful model to study new technology has been in the area of circulating tumor DNA (ctDNA). And the BESPOKE CRC trial is looking to see if ctDNA can inform adjuvant treatment decisions for stage II and III colorectal cancer. And in Abstract 15, we heard final results of the BESPOKE CRC sub-cohort. What were the findings there? Dr. David Wang: BESPOKE CRC is another one of these important ctDNA studies. It was an observational study, not a randomized trial, but it did provide a lot of different insights to us. We know that there were over 1,700 patients enrolled, and so it was reported that this is the largest ctDNA study in colorectal cancer performed in the United States. And they were able to analyze over 1,100 patients.  Some of the key findings were that postoperative adjuvant therapy management decisions actually changed in 1 out of 6 patients, so that's pretty significant. In terms of surveillance, we know that patients who have ctDNA positivity, this is prognostic of recurrence. In terms of patients who have positive ctDNA post-surgery, it looked like, at least in this observational study, the majority of patients who received any benefit were those who had positive ctDNA. So adjuvant therapy, even in stage II and stage III patients seemed to only benefit those patients who have positive ctDNA. I think that does raise the question, and this also was brought up in the discussion, which is “Can we de-escalate adjuvant therapy in terms of patients who are ctDNA-negative post-op?” And Dr. Richard Kim from Moffitt felt that we are not yet there. Obviously, we need randomized control trials where we are taking ctDNA results and then randomizing patients to receive adjuvant or non-adjuvant to really know the difference.  Other questions that come up with use of ctDNA include: What do you do with these patients who turn positive? This study for BESPOKE actually followed patients out to two years after surgery. So what you do with a positive ctDNA result wasn't really clear. It seems to suggest that once you turn positive, patients go on to more intensive surveillance. You know, again as an observation, patients who did turn positive were able to go to metastasis-directed therapy much more quickly. And again, this was supposedly to improve their curative intent therapy. And I think the other question that has been brought up all the time is, is this really cost effective? Patients want to know, and we want to give patients that information, but I think we're still stuck with what to do with a positive ctDNA level in a patient that's on surveillance because no randomized control studies have actually suggested that we need to start systemic therapy right away. Dr. Shaalan Beg: Yeah. And I guess in terms of practice informing or practice changing, these results may not give us a clear answer. But because a lot of patients are asking for these tests, it does give us some real world experiences on what to expect in terms of conversion of these positive into negative and the outcome so we can have a shared decision making with our patients in the clinic and then come up with a determination on whether ctDNA for molecular residual disease is something which would be worthwhile for the care of our patient. But more to come, I guess, in coming years to answer different problems around this challenge. Dr. David Wang: Yes, I agree. Dr. Shaalan Beg: The BREAKWATER trial looked at the use of encorafenib, cetuximab and chemotherapy for BRAF V600E-mutant metastatic colorectal cancer. We've covered this combination for a second- third-line treatment in metastatic colorectal cancer previously. Abstract 16 from GI25 was evaluating the use of this regimen in the first-line space. Everyone was looking forward to these results, and what did the investigators present? Dr. David Wang: I think this is, as you mentioned, a nice follow up to later lines of therapy where Dr. Kopetz from MD Anderson pioneered use of encorafenib, cetuximab and binimetinib in the BEACON trial. Everybody was kind of curious what would happen now if you use encorafenib plus cetuximab plus chemotherapy in the first-line setting. And so this is an interim analysis that was pre-planned in the phase 3 open label BREAKWATER trial. And even though there were three arms, and so the three arms were encorafenib plus cetuximab, encorafenib plus cetuximab plus FOLFOX, or standard of care chemo, only two arms were presented in the abstract. So basically looking at encorafenib plus cetuximab and FOLFOX-6 versus standard of care therapy, and the overall response rate was statistically significant with a 60.9% overall response rate encorafenib plus cetuximab plus chemo arm versus standard of care chemo was only 40%. The interim overall survival also was different. It was 92% versus 87% at 6 months and 79% versus 66% at 12 months, again favoring the chemotherapy plus encorafenib plus cetuximab. In terms of the statistics, the p was 0.0004. However, the pre-plan analysis required the p-value to be 1x10 to the -8. And so even though this looks really good, it hasn't quite met its pre-specified significance level. The good thing is that this is only interim analysis and the study is ongoing with future analysis planned.  So the real question is: Does it matter when we actually use this regimen? We know that the regimen's approved in the second third-line setting. What about in the first line? And there was some preclinical data that the discussant reviewed that shows that patients actually benefit if this is done in the first-line setting. For example, there was some preclinical data showing that even FOLFIRI, for example, can upregulate RAS, which would make tumors more resistant to this combination. This was thought to be practice-changing in a patient that has B600E showing up treatment naive that we should probably consider this regimen. And actually this did receive accelerated FDA approval about a month ago. Dr. Shaalan Beg: Yeah, and for what it's worth, I put up a Twitter poll asking my Twitter followers on how the BREAKWATER trial results will change their approach for newly diagnosed BRAF mutated colorectal cancer. We got 112 responses; 72% said that they will incorporate encorafenib, cetuximab, FOLFOX for their frontline BRAF mutated patients. But 23% said that they would like to wait for overall survival results. Dr. David Wang: Wow, that's interesting. They really want that 1x10 to the -8. Dr. Shaalan Beg: I guess so. All right. Let's change gears and talk about esophageal cancer. LBA329 was the SCIENCE study which presented preliminary results from a randomized phase 3 trial comparing sintilimab and chemoradiotherapy plus sintilimab versus chemoradiotherapy for neoadjuvant resectable locally advanced squamous esophageal cancer. Where are we in this space? Dr. David Wang: Okay. So, yeah, this was an interesting trial. Again, just to set the context, esophageal squamous cell carcinoma is more prevalent in Asia. And the study sites as well as the patients were mostly from Asia. So this was again a phase 3 trial with interim results. They only rolled 146 out of the planned 420 for this interim analysis. And yeah, they're using immune checkpoint inhibitor that we don't use in the United States, sintilimab, combined with their two standards of neoadjuvant therapy, either chemotherapy, which is more common in Asia, or or chemoradiation, which is more common in the US and Western Europe, versus chemoradiation. And so they actually had two primary endpoints, but only were reporting one. So their two primary endpoints were pathCR and the other one was event-free survival. The event-free survival, again, was not reported at the meeting.  What they found was that in terms of pathCR rate, if you take the two arms that are really informative about that, chemoradiation plus sintilimab versus chemoradiation alone, the pathCR rate was 60% versus 47%. We know that chemo alone doesn't induce as much of a pathCR rate, and that was 13%. So it was found that the delta in terms of pathCR between the chemoradiation arms, one with sintilimab and one without, was significant. And this actually confirms data again from Asia, like for the ESCORT-NEO trial where it used another immune checkpoint inhibitor pembrolizumab in addition to neoadjuvant chemo.  So as our discussant for this abstract said, yes, we know that radiation combined with chemotherapy improves pathCR rates, but we have recent data from the ESOPEC trial, we don't know that that necessarily will translate to overall survival. So again, waiting for additional enrollments and longer term follow up before incorporating this into clinical care here. Dr. Shaalan Beg: So David, how do the results of the SCIENCE trial compare with our practice in the United States and ongoing studies asking questions for neoadjuvant therapy for esophageal carcinoma in the United States? Dr. David Wang: I think obviously immune checkpoint inhibitor in the new adjuvant setting is important. Jennifer Eads at UPenn is running that EA2174 which is looking at chemoradiation plus or minus nivolumab, and then in non-pathCR responders randomized to adjuvant nivolumab per CheckMate 577 or nivolumab with intensification adding ipilimumab. We know that the ESOPEC trial just came out, and was published actually during the meeting, and that really focuses on adenocarcinomas. So adenocarcinomas of the GE junction, distal esophagus, now, we would probably treat very similarly to gastric using perioperative FLOT. However, the standard in the US for esophageal squamous cell carcinoma remains neoadjuvant chemoradiation. We know that squamous cell carcinomas are more exquisitely sensitive to radiotherapy. And then obviously in those patients who don't achieve a pathologic complete response, the expectation would be that they would go on to receive nivolumab per CheckMate 577. Again, the thought is that these tumors are more sensitive to immunotherapy given their higher incidences of mutational changes. And so again, this kind of goes along with the positive results seen in the SCIENCE trial that we just discussed with sintilimab but also EFFECT-neo with pembrolizumab. Obviously, we await the results of Jennifer's trial. Dr. Shaalan Beg: And the last abstract I was hoping we could get your perspective on was Abstract 652, which is a Phase 3 study of everolimus plus lanreotide versus everolimus monotherapy for unresectable or recurrent gastroenteropancreatic neuroendocrine tumors, the STARTER-NET trial. What were the results of this study? Dr. David Wang: So, I just want to give a shout out because we did have a session at this year's GI ASCO that looked at more rare tumors. So appendiceal tumors, neuroendocrine tumors, those kinds of things. So again, I would encourage your listeners to listen to that session if they have interest in that. Another type of rare tumor was adenosquamous tumors.  But in terms of the STARTER-NET trial, this was again an interim analysis of his phase 3trial and it was looking at combining everolimus plus lanreotide versus everolimus. So we know that in pancreatic-gastric neuroendocrine tumors, if you have low Ki-67, a well differentiated tumor, that the standard of care really is a somatostatin analog, and sometimes if they're more aggressive, we kind of consider molecular targeted therapy with everolimus. This was asking the question of whether we should do the combination on the frontline. And what was interesting is in this study, the patients were actually more of a poor prognostic set. So they had Ki-67 up to 20% or these were patients that actually had multiple liver lesions. And what they found was a median for progression free survival was improved with a combination out to 29.7 months versus 11.5 months with the somatostatin analog alone, and that the overall response rate was 23% versus 8.3%, again, favoring the combination. If you looked at subgroup analysis, it was actually those patients who had Ki-67 greater than 10%, so the more aggressive tumors, or those with diffuse liver lesions that had the most benefit. So I think that would be the patient population I would consider this new combination with using would be those patients again with poorer prognosis neuroendocrine tumor phenotype. Dr. Shaalan Beg: Thank you very much, Dr. Wang, for sharing your insights with us today and your great work to build a robust GI Cancers Symposium this year. Dr. David Wang: Well, thank you. I mean that really is a cooperative effort. We appreciate all the members of the GI25 Program Committee as well as the ASCO staff that just made it an outstanding meeting. Dr. Shaalan Beg: And thank you to all our listeners for your time today. You'll find links to the abstracts discussed today on the transcript of this episode.  Finally, if you value the insights that you hear on the ASCO Daily News Podcast, please take a moment to rate, review and subscribe wherever you get your podcasts. Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.  Guests on this podcast express their own opinions, experience and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement. Find out more about today's speakers:  Dr. Shaalan Beg @ShaalanBeg  Dr. David Wang Follow ASCO on social media:   @ASCO on Twitter  @ASCO on BlueSky ASCO on Facebook   ASCO on LinkedIn   Disclosures:  Dr. Shaalan Beg:  Employment: Science 37  Consulting or Advisory Role: Ipsen, Array BioPharma, AstraZeneca/MedImmune, Cancer Commons, Legend Biotech, Foundation Medicine  Research Funding (Inst.): Bristol-Myers Squibb, AstraZeneca/MedImmune, Merck Serono, Five Prime Therapeutics, MedImmune, Genentech, Immunesensor, Tolero Pharmaceuticals  Dr. David Wang: Honoraria:  Novartis Consulting or Advisory Role: Novartis, Cardinal Health, Bristol-Myers Squibb, BeiGene, Eisai  

Dawn Elliott, Physician Liaison at The Rose, recounts her breast cancer journey with host Dorothy Gibbons. For years, Dawn's gynecologist emphasized the need for a baseline mammogram at 35 despite no family history. Once she turned 35, Dawn scheduled her regular gynecologist appointment, and he noticed a lump during her exam. This led to biopsies revealing stage zero cancer. Dawn's experience propelled her into community outreach, working at MD Anderson and the University of Chicago in cancer genetics and clinical trials. Her current role involves connecting with physicians to share ways The Rose can help patients and providing patient navigation insights. Key Questions Answered 1. How was Dawn Elliott diagnosed with breast cancer? 2.What role did Dr. James McBride play in Dawn's diagnosis? 3. What was the stage and nature of Dawn's cancer diagnosis? 4. Why did Dawn Elliott choose a modified radical mastectomy? 5. Did Dawn Elliott experience any reoccurrence of breast cancer? 6. What kind of work has Dawn been involved in within the breast cancer community? 7. How did Dawn Elliott transition to working at the Rose? 8.What type of support was significant to Dawn as a working single mother? Timestamped Overview 00:00 Gynecologist urges early baseline mammogram at 35. 03:44 Chose mastectomy, showed family living joyfully. 08:48 Dedicated to compassionate patient care and trials. 13:02 Advocated women's health: cancer to heart disease. 14:35 Left Methodist due to funding, joined Rose. 17:16 Wearing pink makes clients happy and smile. 21:00 Late arrival due to child's needs explained. 23:47 Faith and positivity combat breast cancer fears.See omnystudio.com/listener for privacy information.

JCO PO author Dr. David R. Gandara at UC Davis Comprehensive Cancer Center, shares insights into his JCO PO article, “Plasma Proteome–Based Test for First-Line Treatment Selection in Metastatic Non–Small Cell Lung Cancer,” one of the Top Articles of 2024. Host Dr. Rafeh Naqash and Dr. Gandara discuss how the PROphet® blood test supports first-line immunotherapy treatment decisions for metastatic NSCLC patients. TRANSCRIPT  Dr. Rafeh Naqash: Hello and welcome to JCO Precision Oncology Conversations where we bring you engaging conversations with authors of clinically relevant and highly significant JCOPO articles. I'm your host, Dr. Rafeh Naqash, Podcast Editor for JCO Precision Oncology and Assistant Professor at the OU Health Stephenson Cancer Center at the University of Oklahoma.  Today, we are absolutely thrilled to be joined by Dr. David R. Gandara, Professor of Medicine Emeritus, Co-Director of the Center for Experimental Therapeutics and Cancer and Senior Advisor to the Director at UC Davis Comprehensive Cancer Center and also the senior author of the JCO Precision Oncology article entitled “Plasma Proteome–Based Test for First-Line Treatment Selection in Metastatic Non–Small Cell Lung Cancer.” This was one of the top performing articles of 2024, which is one of the reasons why we wanted to bring it in for a podcast discussion. At the time of this recording, our guest's disclosures will be linked in the transcript.  David, it is an absolute pleasure to have you today. For somebody like you who's led the field of lung cancer over the years, I'm really excited that you are going to be talking to us about this very interesting article, especially given that I think you're one of the big proponents of liquid biopsies and plasma-based testing. So, for the sake of our listeners - which comprises of academic oncologists, community oncologists, trainees - could you tell us where the biomarker landscape for non-small cell lung cancer is currently, and then we can try to take a deeper dive into this article. Dr. David Gandar: Okay. Well, thank you, Rafeh. It's a pleasure to be with you here today. And I think the current landscape for biomarkers for immunotherapy in non-small cell lung cancer is a mess. There's no better way to describe it. That makes this paper describing a new plasma proteomic assay even more important. So I'll just give you a perspective. There are 14 trials, phase three trials, that were done in first line non-small cell lung cancer advanced stage of immunotherapy versus chemotherapy and some other aspects, although they vary tremendously. Some of them were checkpoint monotherapy, some combined with chemotherapy, some combined with CTLA-4 inhibitors and so forth. 12 out of the 14 were positive, 12 got FDA approval. So there are 12 different options that an oncologist could use. Some of them were squamous cell only, some non-squamous, some used PD-L1 as a biomarker driven part of the study. Some used TMB, tumor mutational burden, some were agnostic. So when you put all of this together, an oncologist can pick and choose among all these various regimens. And by and large, it's PD-L1 that is the therapeutic decision maker.  ASCO actually, I think, has done the very best job of making a guideline, and it's, as you well know, called a living guideline, it's dynamic. And it is much easier to interpret, for me and I think for oncologists, than some of the other guidelines. It's got a green light and a red light, it may be kind of orange. And so the green light means this is a strong recommendation by the guideline committee. The orange means it's weak. For this purpose, non-small cell lung cancer, advanced stage, only a very few of the recommendations were green. It's mainly monotherapy and patients with cancers with a PD-L1 over 50%. In our surveys, at our meetings, less than 50% of oncologists in the United States are following these guidelines. Why? Because they don't trust the biomarker. And TMB has the same sort of limitations. They're not bad biomarkers, they're incomplete. They're only looking at a part of the story. So that means we need a new biomarker. And this is one that, I think, the data are quite impressive and we'll discuss it more. Dr. Rafeh Naqash: Absolutely. Like you said, abundance of many therapy options, but not necessarily everything works the same in different subsets of PD-L1 positivity or different subsets of patients with different levels of tumor burden. And like you said, again, difficulty in trying to identify the right biomarker. And that's a nice segue to this PROphet test that you guys ran. So can you tell us a little bit about the plasma proteomic assay? Because to the best of my knowledge, there's not a lot of validated plasma proteomic assays. A lot has been done on the tumor tissue side as far as biomarkers are concerned, but not much on the blood side, except for maybe ctDNA MRD testing. So what was the background for trying to develop a plasma-based proteomic test? And then how did this idea of testing it in the lung cancer setting come into play? And then we can go into the patient population specifics, the cohort that you guys have. Dr. David Gandara: Okay. Well, of course there's a company behind this assay, it's called OncoHost, and I'm a consultant for them. And they came to me two years ago and they said, “We have something different from anyone else.” And they explained the science to me, as well as some other lung cancer experts here in the United States. I'm not a proteomic expert, of course, but they developed an AI machine learning platform to assess plasma proteins in normal people and in people with cancer, and specifically then in people with non-small cell lung cancer. They identified over 7,000 proteins that had cancer implications for therapy, for resistance, for prognosis, etc., and they categorized them based on the literature, TCGA data, etc., and used this machine learning process to figure out which proteins might be most specific for non-small cell lung cancer. And that's where they started. And so out of that 7,000 proteins, where they've identified which ones are angiogenic, which ones are involved with EMT or cell cycle or whatever it might be, they distilled it down to 388 proteins which they thought were worth testing in non-small cell lung cancer. And that's when I became involved.  They had a retrospective cohort of patients that had been treated with various immunotherapies. They looked at the analytic validation first, then applied it to this cohort. It looked good. Then they had a very large cohort, which they split, as you usually do with an assay, into a test set and then a validation set. For the test set, they wanted something more than a response. They wanted some indicator of long term benefit because that's where immunotherapy differentiates itself from chemotherapy and even targeted therapy. And so they picked PFS at 12 months. And I became involved at that point and it looked really good. I mean, if you look at the figures in the manuscript, the AUC is superb about their prediction and then what actually happened in the patient. And then in this paper, we applied it to a validation set of over 500 patients in a prospective trial, not randomized, it's called an observational trial. The investigator got to pick what they thought was the best therapy for that patient. And then in a blinded fashion, the proteomic assay experts did the analysis and applied it to the group.  And so what that means is some of the patients got chemotherapy alone, some got checkpoint immunotherapy monotherapy, some got in combination with chemotherapy. None of the patients in this study got a CTLA-4 inhibitor. That work is ongoing now. But what the study showed was that this assay can be used together with PD-L1 as what I would call a composite biomarker. You take the two together and it informs the oncologist about the meaning of that PD-L1. I'll give you an example. If that patient has a PD-L1 over 50% in their cancer and yet the PROphet test is negative, meaning less than 5 - it's a 0 to 10 scale - that patient for survival is better served by getting chemotherapy and immunotherapy. However, if the PROphet test is positive and the PD-L1 is over 50%, then the survival curves really look equivalent. As I said earlier, even in that group of patients, a lot of oncologists are reluctant to give them monotherapy. So if you have a test and the same sort of example is true for PD-L1 0, that you can differentiate. So this can really help inform the oncologist about what direction to go. And of course then you use your clinical judgment, you look at what you think of as the aggressiveness of the tumor or their liver metastases, etc. So again, that's how this test is being used for non-small cell lung cancer. And maybe I'll stop there and then I'll come back and add some other points. Dr. Rafeh Naqash: I definitely like your analogy of this therapy de-escalation strategy. Like you mentioned for PD-L1 high where the PROphet test is negative, then perhaps you could just go with immunotherapy alone. In fact, interestingly enough, I was invited to a talk at SITC a couple of weeks back and this exact figure that you're referring to was one of the figures in my slide deck. And it happened by chance that I realized that we were doing a podcast on the same paper today.  So I guess from a provocative question standpoint, when you look at the PD-L1 high cohort in the subset where you didn't see a survival difference for chemo plus immunotherapy versus immunotherapy alone, do you think any element of that could have been influenced by the degree of PD-L1 positivity above 50%? Meaning could there have been a cohort that is, let's say PD-L1 75 and above, and that kind of skews the data because I know you've published on this yourself also where the higher the PD-L1 above 50%, like 90% PD-L1 positivity survival curves are much better than 50% to 89%. So could that have somehow played a role? Dr. David Gandara: The first thing to say is that PD-L1 and the PROphet score, there's very little overlap. I know that sounds surprising, but it's also true for tumor mutational burden. There's very little overlap. They're measuring different things. The PD-L1 is measuring a specific regulatory protein that is applicable to some patients, but not all. That's why even in almost all of the studies, people with PD-L1 0 could still have some survival benefit. But in this case they're independent. And not in this paper, but in other work done by this group, the PROphet group, they've shown that the PROphet score does not seem to correlate with super high PD-L1. So it's not like the cemiplimab data where if you have a PD-L1 of greater than 90%, then of course the patient does spectacularly with monotherapy. The other thing that's important here is they had a group of around a little less than 100 patients that got chemotherapy alone. The PROphet score is agnostic to chemotherapy. And so that means that you're not just looking at some prognostic factor. It's actually clinical utility on a predictive basis. Dr. Rafeh Naqash: I think those are very important points. I was on a podcast a couple of days back. I think there's a theme these days we're trying to do for JCO Precision Oncology, we're trying to do a few biomarker based podcasts, and the most recent one that we did was using a tissue transcriptome with ctDNA MRD and you mentioned the composite of the PD-L1 and the PROphet test and they use a composite of the tissue transcriptome. I believe they called it the VIGex test as well as MRD ctDNA. And when your ctDNA was negative at, I believe, the three month mark, those individuals had the highest inflamed VIGex test or highest infiltration of T cells, STING pathway, etc. So are there any thoughts of trying to add or correlate tissue based biomarkers or ctDNA based correlations as a further validation in this research with the company? Dr. David Gandara: Right. So there are many things that are being looked at, various composites looking at the commutations that might affect the efficacy of immunotherapy and how they correlate with profit positivity or negativity. And I'll just give the examples of STK11 and KEAP1. As you know, there's some controversy about whether these are for immunotherapy, whether they're more prognostic or predictive. I'm one of the co-authors among many in the recently published Nature paper by Dr. Skoulidis and the group at MD Anderson which report that for KEAP1 positive especially, but also SDK11 mutated getting immunotherapy, that that's where the CTLA-4 inhibitors actually play the greatest role. So realizing that this is still controversial, there are preliminary data, not published yet, that'll be presented at an upcoming meeting, looking at many of these other aspects, P53, SCK11, KEAP1, other aspects, TMB, that's actually already published, I think in one of their papers. So yes, there's lots of opportunities.  The other cool thing is that this isn't a test, it's a platform. And so that means that the OncoHost scientists have already said, “What if we look at this test, the assay in a group of patients with small cell lung cancer?” And so I just presented this as a poster at the world conference in San Diego. And it turns out if you look at the biology of small cell, where neither PD-L1 nor TMB seem to be very important, if you look at the biology of small cell and you form an assay, it only shares 44 proteins out of the 388 with non-small cell. It's a different biology. And when we applied that to a group of patients with small cell lung cancer, again it had really pretty impressive results, although still a fairly small number of patients. So we have a big phase three study that we're doing with a pharmaceutical company developing immunotherapy where we are prospectively placing the PROphet test in a small cell trial.  The platform can also be altered for other cancer types. And at AACR, Dr. Jarushka Naidoo presented really impressive data that you can modify the proteins and you can predict immunotherapy side effects. So this is not like a company that says, “We have one test that's great for everything.” You know how some companies say, “Our test, you can use it for everything.” This company is saying we can alter the protein structures using AI machine learning assisted process to do it and we can have a very informed assay in different tumor types and different situations. So to me, it's really exciting. Dr. Rafeh Naqash: Definitely to me, I think, combining the AI machine learning aspect with the possibility of finding or trying to find a composite biomarker using less invasive approaches such as plasma or blood, definitely checks a lot of boxes. And as you mentioned, trying to get it to prospective trials as an integral biomarker perhaps would be likely the next step. And hopefully we see some interesting, exciting results where we can try to match or stratify patients into optimal combination therapies based on this test.  So now to the next aspect of this discussion, David, which I'm really excited about. You've been a leader and a mentor to many. You've led ISLC and several other corporate group organizations, et cetera. Can you tell us, for the sake of all the listeners, junior investigators, trainees, what being a mentor has meant for you? How your career has started many years back and how it's evolved? And what are some of the things that you want to tell people for a successful and a more exciting career as you've led over the years? Dr. David Gandara: Well, thank you for the question. Mentoring is a very important part of my own career. I didn't have an institutional mentor when I was a junior investigator, but I had a lot of senior collaborators, very famous people that kind of took me under their wing and guided me. And I thought when I basically establish myself, I want to give back by being a mentor to other people. And you wouldn't believe the number of people that I'm even mentoring today. And some of them are not medical oncologists, they're surgeons, they're radiation oncologists, they're basic scientists. Because you don't have to be an expert in that person's field to be a mentor. It helps, but in other words, you can guide somebody in what are the decision making processes in your career. When is it time to move from this institution onward because you can't grow in the institution you're in, either because it's too big or it's too small? So I established a leadership academy in the Southwest Oncology Group, SWOG. I've led many mentoring courses, for instance, for ISLC, now for International Society Liquid Biopsy, where I'm the executive committee liaison for what's called The Young Committee. So ISLB Society, totally devoted to liquid biopsy, six years old now, we have a Young Committee that has a budget. They develop projects, they publish articles on their own, they do podcasts. So what I'm saying is those are all things that I think opens up opportunities. They're not waiting behind senior people, they are leading themselves.  We just, at our International Lung Cancer Congress, reestablished a fellows program where a group of fellows are invited to that Huntington beach meeting. It's now in its 25th year and we spend a day and a half with them, mentoring them on career building. I'll just give you my first, I have the “Letterman Top 10”. So my first recommendation is if all you have is lemons, make lemonade. And what I'm meaning is find what you can do at your institution if you're a junior person, what you can claim to be your own and make the very best of it. But then as you get further along in my recommendations, one of them is learn when to say ‘no'. Because as a junior investigator the biggest threat to your career is saying ‘yes' to everybody and then you become overwhelmed and you can't concentrate. So I'll stop there. But anyway, yes, mentoring is a big part of my life. Dr. Rafeh Naqash: Well, thank you, David. This is definitely something that I'm going to try to apply to my career as well. And this has been an absolute pleasure, especially with all the insights that you provided, not just on the scientific side but also on the personal career side and the mentorship side. And hopefully we'll see more of this work that you and other investigators have led and collaborated on. perhaps more interesting plasma based biomarkers. And hopefully some of that work will find its home in JCO Precision Oncology. Thank you again for joining us today. Dr. David Gandara: My pleasure. Dr. Rafeh Naqash: And thank you for listening to JCO Precision Oncology Conversations. Don't forget to give us a rating or review and be sure to subscribe so you never miss an episode. You can find all ASCO shows at asco.org/podcasts.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.  Guests on this podcast express their own opinions, experience and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service organization, activity or therapy should not be construed as an ASCO endorsement.   Dr. David Gandara Disclosures: Consulting or Advisory Role Company: Henlius USA, Foundation Medicine, Janssen Pharma, Merck & Co, Mirati Therapeutics, Regeneron, AstraZeneca, Guardant Health, Genentech, Exact Sciences  Research Funding Company: Amgen, Genentech, Astex Pharma  

We pay for the California fires and all disasters as a form of subsidy to the rich. Why doesn't MD Anderson accept Affordable Care Act insurance plans? The answer is complicated. Subscribe to our Newsletter: https://politicsdoneright.com/newsletter Purchase our Books: As I See It: https://amzn.to/3XpvW5o How To Make America Utopia: https://amzn.to/3VKVFnG It's Worth It: https://amzn.to/3VFByXP Lose Weight And Be Fit Now: https://amzn.to/3xiQK3K Tribulations of an Afro-Latino Caribbean man: https://amzn.to/4c09rbE

We pay for the California fires and all disasters as a form of subsidy to the rich. Why doesn't MD Anderson accept Affordable Care Act insurance plans? The answer is complicated. Subscribe to our Newsletter: https://politicsdoneright.com/newsletter Purchase our Books: As I See It: https://amzn.to/3XpvW5o How To Make America Utopia: https://amzn.to/3VKVFnG It's Worth It: https://amzn.to/3VFByXP Lose Weight And Be Fit Now: https://amzn.to/3xiQK3K Tribulations of an Afro-Latino Caribbean man: https://amzn.to/4c09rbE

Join me for my next live video in the app* We pay for the California fires and all disasters as a form of subsidy to the rich: Every time you see wildfires, hurricanes, floods, tornados, and the destruction they cause, you are witnessing the poor and middle class subsidizing the rich. [More]* Why doesn't MD Anderson accept Affordable Care Act insurance plans? The answer is complicated: MD Anderson is one of the best cancer centers in the nation, offering cutting-edge treatments that attract patients from around the world. But that treatment is likely out of reach for millions of people covered by health insurance plans through the Affordable Care Act. [More] To hear more, visit egberto.substack.com

In this heartfelt episode of the Revelations Podcast, Reagan Kramer welcomes Tom and JoAnn Doyle, leaders of Uncharted Ministries, to share their incredible journey of faith, ministry, and miracles. From life-changing dreams and visions of Jesus in the Muslim community to the untapped power of women in advancing the gospel, this episode is packed with stories that uplift and inspire. This episode shines a light on the supernatural ways God is reaching people in some of the darkest corners of the world, offering hope where there seems to be none. And the pathway through which the river of God's love flows may be you.God is omnipresent, all-powerful, and all-knowing. He will come to us in the most unlikely places. He might appear in the form of a stranger offering a kind hand and word. Alternatively, God may show Himself to you as a vision, whether a waking dream or one that appears to you in your sleep. But sometimes, it is not to you that God appears, but people find God through you.By tuning in to this episode, you'll gain a renewed perspective on the power of prayer, the depth of God's love, and how ordinary people can play extraordinary roles in God's plan. If you've been wondering what part you have to play in the divine work, let this episode challenge and encourage you to see opportunities to be God's light.Here are three reasons why you should listen to this episode:Understand how dreams and visions can be God's way of meeting us no matter where we are, showing how he relentlessly pursues the salvation of every soul.Find out about how we are all called to spread the Gospel and help everyone find God, especially those different from us.Learn how to navigate spiritual battles and wrap yourself in the spiritual armor of God to persevere through any darkness.Become Part of Our Mission! Support The Revelations Podcast:Your support fuels our mission to share transformative messages of hope and faith. Click here to learn how you can contribute and be part of this growing community!ResourcesMore from the Revelations Podcast hosted by Reagan Kramer: Website | Instagram | Apple Podcast | YoutubeUncharted MinistriesDreams and Visions by Tom DoyleWomen Who Risk by JoAnn DoyleBlurry CreaturesI Found the Truth MinistryBible VersesEphesians 1:17Ephesians 6John 14:6Acts 2Matthew 28:19-20This Episode is brought to you by Advanced Medicine AlternativesGet back to the active life you love through natural & regenerative musculoskeletal healing: https://www.georgekramermd.com/Episode Highlights[0:09] Meeting Tom and JoAnnReagan introduces Tom and JoAnn Doyle, the hosts of Uncharted Ministries. Tom recently recovered from stage four cancer — a true miracle from God.Of the two, Tom is the primary storyteller. JoAnn provides feminine commentary.Reagan found Tom's book to be a powerful personal experience, challenging her faith and making her review how she lived.[04:02] Uncharted MinistriesJoAnn explains their ministry's history, starting with Bible trips in Israel and Jordan and transitioning to working in the Middle East post-9/11.Tom and JoAnn emphasize their commitment to working with both Jews and Muslims, highlighting God's big heart for both groups.Tom and JoAnn discuss the challenges and opportunities in the Middle East, including the spiritual warfare and the openness of Muslims to the Gospel.They share stories of Muslims having dreams and visions about Jesus, which have become more common post-9/11.Tom and JoAnn emphasize the importance of God's love disarming people and their approach of winning people over with love rather than defensiveness.[15:12] Impact of Dreams and VisionsTom explains why Jesus comes to Muslims in dreams, referencing the Islamic tradition of dreams and visions.He describes the Night of Power during Ramadan as a significant time when many Muslims have dreams about Jesus.JoAnn adds that many Muslims are searching for answers and are open to the Gospel, often feeling unfulfilled by their current faith.Reagan shares a personal story of meeting a Muslim woman in a coffee shop and how it led to a spiritual conversation that helped them both find God.[23:58] The Role of Women in MinistryTom and JoAnn discuss the significant role of women in their ministry, particularly as spiritual gatekeepers in Muslim families.They share stories of women coming to faith in Christ and the impact it has on their families and communities.JoAnn emphasizes the importance of women in the New Testament and their role in supporting and providing for Jesus and the disciples.Reagan and JoAnn discuss the importance of women in America recognizing their value and purpose in God's plan.[27:52] Approaching Spiritual Warfare Through PrayerTom and JoAnn describe the intense spiritual warfare in the Muslim world and the importance of prayer and the armor of God.They share personal experiences of feeling the oppressive spiritual darkness in the Muslim Quarter of Jerusalem.Tom recounts a story of praying for a man in a refugee camp in Gaza, who later requested prayers for his family.JoAnn emphasizes the importance of putting on the armor of God and praying for protection and strength in spiritual battles.[33:32] Christians and Muslims: Together in FaithTom and JoAnn share stories of encounters with Muslims, including a woman in Egypt who had a dream about them and a man in Jordan who had a dream about his son.They describe how these encounters lead to opportunities to share the Gospel and bring people to find God and faith in Christ.JoAnn shares a story of meeting a woman in a niqab at MD Anderson and how it led to a meaningful conversation and prayer.They emphasize the importance of being open to opportunities and not being afraid to engage with Muslims.[42:40] How People Find God in DreamsTom and JoAnn discuss the varied nature of dreams Muslims have about Jesus, including specific messages and encounters.They share a story of a woman who had a dream about Jesus after praying "Who are you?" and how it led her to faith.Tom recounts a story of a man in Egypt who had a dream about Rami and later came to faith after Rami visited him.These dreams were powerful, personal, and intimate. The deepness of their connection is how they lead people to seek Jesus.[54:06] You Can Expect MiraclesTom shares about his current health crisis and the power of prayer and support from believers around the world.JoAnn emphasizes the importance of not giving up hope and continuing to pray no matter the darkness. Never stop praying for your loved ones.Reagan herself had a personal experience of praying for a supernatural encounter with God for a friend — and it led to spiritual awakening.As Christians, we are challenged to be light and share the love of Jesus wherever we are, even in difficult circumstances.[1:05:49] Encounter with Maria at the Gas StationTom shares a story about a conversation with a woman named Maria at a gas station in Dallas. Maria says she had been having dreams about Jesus for over 30 years.Meeting Maria was a moment where Tom received an assignment from God. He gave Maria a book about dreams and visions, which resonated deeply with her.Maria had been praying to find God and Jesus. Meeting Tom was unexpected, but it was through him that God reached out to Maria.Reagan and JoAnn discuss the timing and coincidence of the gas station meeting. There are people waiting to hear about Jesus everywhere, not just in specific locations.[1:09:55] The Role of Influential Believers in Sports and MediaNFL football stars who believe and share their faith can have a powerful impact on their viewership and followers.Social media is a powerful force in the modern era; JoAnn mentions multiple Christian podcasts, such as Blurry Creatures, that let people stumble upon Jesus and find God.Believers in sports and media have been invaluable when it comes to spreading the gospel. Their reach is wide, and can touch anyone regardless of age or origin.These people may be a hope for securing the faith in the U.S. and shows the importance of sharing the Gospel through various platforms.[1:13:07] Prayer for Believers Worldwide to Find GodTom and Reagan encourage listeners to reach out to Muslims and share the Gospel.They then lead a prayer for listeners, asking for God's guidance and encouragement, and perseverance in the face of difficulty.Tom and JoAnn pray for Muslims to consider the gospel and read the Bible, and express their love for Jesus. May all people know Him more deeply.Reagan blesses JoAnn and Tom, praying for their healing and continued ministry, while praising God for the miracles and the Holy Spirit's boldness in their lives.About Tom DoyleTom Doyle is the President and Founder of Uncharted Ministries, an organization dedicated to reaching the unreached and standing with the persecuted, particularly among Jews and Muslims in the Middle East and other uncharted territories. His journey into Middle Eastern ministry began in 1995 when he became an official tour guide for Israel, fostering a deep passion for the region and its people.In 2001, following a divine calling, Tom and his wife, JoAnn, transitioned into full-time ministry focused on the Middle East, Central Asia, and North Africa. Tom is also a prolific author, known for books such as Dreams and Visions, Killing Christians, and Standing in the Fire, which highlight God's miraculous work among Muslim communities. His most recent work, Women Who Risk — Secret Agents for Jesus in the Muslim World, co-authored with JoAnn, shares compelling stories of Muslim women transformed by Jesus.Beyond his literary contributions, Tom is a sought-after international speaker, sharing firsthand accounts of faith and perseverance from some of the world's most challenging regions.About JoAnn DoyleJoAnn Doyle is the President and Founder of Not Forgotten, the women's ministry division of Uncharted Ministries, focusing on reaching and empowering women in the Middle East, North Africa, and Central Asia, with a particular emphasis on Muslim women. Married to Tom for over 38 years, JoAnn was a pastor's wife for two decades before embracing a full-time calling to the Middle East in 2001.Her ministry journey led her to establish Not Forgotten, through which she leads expeditions, conducts training, and speaks in churches across North America, inspiring women to engage Muslim women with the love and message of Christ. JoAnn is also a co-author of Women Who Risk — Secret Agents for Jesus in the Muslim World, alongside her husband, Tom, sharing riveting stories of transformation among Muslim women.Her dedication to worship, prayer, and family underscores her commitment to living out her faith in both personal and ministry contexts.Connect with JoAnn and Tom on their website, Uncharted Ministries.Enjoyed this Episode?If you did, subscribe and share it with your friends!Post a review and share it! If you found our deep dive into the spiritual influences on mental health insightful, we'd love to hear your thoughts. Leave a review and share this episode with friends and family. Encourage others to find God in all things — whether in a dream, a chance encounter, or in themselves.Have any questions? You can connect with me on Instagram.Thank you for tuning in! For more updates, tune in on Apple Podcasts

Private equity and venture capital have been reshaping the healthcare landscape, with $47 billion in related deals recorded from 2019 to 2023. These investments promise innovation and growth in AI, diagnostics, and healthcare delivery. However, they also raise critical questions about aligning profit-driven goals with the mission to improve patient care and system efficiency. At a time when the U.S. healthcare system faces mounting inefficiencies and inequities, this influx of private capital demands a closer look.What does private equity mean for the future of healthcare? Will it spark meaningful innovation or deepen existing challenges in accessibility, affordability, and patient outcomes?On this episode of I Don't Care, host, Dr. Kevin Stevenson, sits down with Dr. Roy Smythe, a distinguished thoracic surgeon turned venture capital advisor. Together, they explore the impact of private equity and venture capital investments on healthcare systems and physician practices. The discussion uncovers both the opportunities and potential pitfalls of private capital in healthcare.Episode Highlights:Private Equity and Healthcare Systems: Dr. Smythe critiques the influx of private capital in hospitals and physician groups, suggesting that profit motives can conflict with the mission of patient care and systemic improvement.Advancements in AI and Proteomics: The discussion delves into how AI can improve efficiency and allow for better clinician-patient interactions, while proteomics offers groundbreaking diagnostic potential by analyzing proteins rather than genes.Systemic Inefficiencies and Underinvestment: The U.S. healthcare system remains hampered by a lack of investment in primary care, leading to increased reliance on costly, advanced care. This has perpetuated inequities and inefficiencies despite significant technological progress.Dr. Roy Smythe is a transformational leader with a diverse background in healthcare innovation, translational bioscience, and medical technology. His career includes executive roles at SomaLogic, Philips, and MD Anderson, where he has driven advancements in diagnostics, AI, and life sciences. With a strong foundation in clinical care and strategic leadership, Dr. Smythe has been at the forefront of bridging medicine and technology to improve healthcare delivery.

Dr. Van Morris presents the new evidence-based guideline on systemic therapy for localized anal squamous cell carcinoma. Dr. Morris discusses the key recommendations from the Expert Panel, including recommended radiosensitizing chemotherapy agents, dosing and schedule recommendations, the role of induction chemotherapy and ongoing adjuvant chemotherapy, and considerations for special populations. He emphasizes the importance of this first guideline from ASCO on anal squamous cell carcinoma for both clinicians and patients with stage I-III anal cancer, and ongoing research the panel is looking to for the future. Read the full guideline, “Systemic Therapy for Stage I-III Anal Squamous Cell Carcinoma: ASCO Guideline” at www.asco.org/gastrointestinal-cancer-guidelines. TRANSCRIPT This guideline, clinical tools, and resources are available at http://www.asco.org/gastrointestinal-cancer-guidelines. Read the full text of the guideline and review authors' disclosures of potential conflicts of interest in the Journal of Clinical Oncology, https://ascopubs.org/doi/10.1200/JCO-24-02120 Brittany Harvey: Hello and welcome to the ASCO Guidelines podcast, one of ASCO's podcasts, delivering timely information to keep you up to date on the latest changes, challenges and advances in oncology. You can find all the shows, including this one at asco.org/podcasts. My name is Brittany Harvey and today I'm interviewing Dr. Van Morris from MD Anderson Cancer Center, co-chair on “Systemic Therapy for Stage I-III Anal Squamous Cell Carcinoma: ASCO Guideline.” Thank you for being here today, Dr. Morris. Dr. Van Morris: Thank you for having me. On behalf of our committee who put together the guidelines, I'm really excited to be here and talk with you today. Brittany Harvey: Great. Then, before we discuss this guideline, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO Conflict of Interest Policy is followed for each guideline. The disclosures of potential conflicts of interest for the guideline panel, including Dr. Morris, who has joined us here today, are available online with the publication of the guideline in the Journal of Clinical Oncology, which is linked in the show notes. So then, to jump into the content of this guideline, Dr. Morris, can you provide an overview of both the purpose and the scope of this guideline on stage I to III anal squamous cell carcinoma? Dr. Van Morris: So anal cancer is considered a rare malignancy for patients in the United States and across the world as well. Even though it's not something we see as commonly, for example, as the adjacent colorectal cancer, this still is a cancer that is rising in incidence every year in the United States. And really, despite the presence of the preventative HPV vaccines, which we hope will ultimately prevent and eradicate this cancer, we still expect the incidence to continue to rise in the coming decades before we really start seeing numbers begin to decrease as a result of the vaccine. So this is an alarming trend for which oncologists will continue to see likely more and more cases and new diagnoses every year. So we wanted to review the most recent literature and provide oncologists up to date recommendations for how they can best take care of patients with a new diagnosis of localized anal cancer. Brittany Harvey: Absolutely. I appreciate that background and context to set the stage for this guideline. So then next I'd like to review the key recommendations of this guideline. So starting from the first clinical question, what are the recommended radiosensitizing, doublet or single chemotherapy agents for patients with stage I to III anal cancer? Dr. Van Morris: It's true that really the standard treatment for patients with localized anal cancer has not changed over the last literally half century. When the Nigro regimen was first reported back in 1974, 50 years ago, the standard of care for patients with a new diagnosis of localized anal cancer centers around concurrent chemotherapy and radiotherapy. And we looked at the various randomized control trials and the highest level of evidence which has been reported over the past decades, and really for most patients, the standard of care continues to remain doublet cytotoxic chemotherapy in combination with radiation. We reported that the most commonly, and I think most accepted, regimen here is a combination regimen of 5-FU, intravenous 5-fluorouracil with mitomycin C. And this most commonly is given on a week 1 to 5 regimen. The 5-FU, we recommended a dose of 1000 milligrams per meter squared per day on days 1 to 4 and then on days 29 to 32 of the radiation treatment. And then the mitomycin C, looking at various trials, has been given at a dose of 10 milligrams per meter squared on day 1 and day 29, or alternatively a single dose of mitomycin C at 12 milligrams per meter squared on day 1. I think that the thing that's important for clinicians and patients alike to remember is that this chemotherapy can be very toxic in patients who are undergoing a curative-intent therapy for this diagnosis of localized anal cancer. I think it's just important for oncologists to be watching closely the blood counts for the patients to make sure that the myelosuppression doesn't get too bad. And then in select cases, if that is the case, when the oncologist opts to go for the day 1 and day 29 dosing, it may be prudent, if the myelosuppression is too excessive, to consider withholding that day 29 dose. Brittany Harvey: Great. Thank you for providing those recommendations along with some of those dosing and the schedule recommendations from the expert panel. So are there any other alternate dose or schedule recommendations from the expert panel? Dr. Van Morris: Yeah, but I think that we saw with the ACT II data that was a randomized trial that was done out of the UK that compared 5-FU mitomycin with 5-FU cisplatin as two different doublet cytotoxic regimens, that overall outcomes were very similar between the two regimens in terms of curative outcomes for patients treated whether 5-FU mitomycin or 5-FU cisplatin. So certainly there is evidence supporting the use of cisplatin as a second cytotoxic agent with 5-fluorouracil. In the ACT II study that was given at a dose of 60 milligrams per meter squared on days 1 and 29 along with the 5-FU at the regimen I talked about previously. There is other lower level of evidence data suggesting that even the 5-FU and cisplatin can be given on a weekly schedule and that that can be safe. Actually, at my institution at MD Anderson, that is our standard practice pattern as well. There's also the option when we're thinking about giving pelvic radiation for patients with lower GI cancers, many oncologists in the treatment of localized rectal adenocarcinoma are accustomed to using capecitabine as a chemosensitizer in patients with localized rectal cancer. If I'm giving chemoradiation for a patient with localized anal cancer, can I substitute the intravenous 5-FU with oral capecitabine? And although the evidence is not as strong in terms of available data with regards to randomized controlled trials, there certainly is data that suggests that capecitabine may be an acceptable alternative in lieu of intravenous 5-fluorouracil that would be given at a dose of 825 milligrams per meter squared on days of radiation. But certainly, I think that that's a feasible approach as well and maybe even associated with less hematologic toxicity than intravenous 5-FU would be. Brittany Harvey: Great. It's important to understand all the options that are out there for patients with early-stage anal squamous cell carcinoma. So in addition to those chemoradiation recommendations, what is recommended from the expert panel regarding induction chemotherapy or ongoing adjuvant chemotherapy for this patient population? Dr. Van Morris: When we think about treating patients with lower GI cancers with curative intent therapies, when we think about the more common rectal adenocarcinoma, oncologists may be used to giving chemoradiation followed by subsequent cytotoxic chemotherapy. But actually when you look at the data for anal cancer, really there's not any data that strongly supports the use of either induction chemotherapy prior to chemoradiation or adjuvant post-chemoradiation chemotherapy. The RTOG 98-11 study was a trial which evaluated the role of induction 5-fluorouracil prior to chemoradiation and did not show any survival benefit or improved outcomes with the use of induction chemotherapy in a randomized control trial setting. The ACT II trial, which I referenced earlier, was a 2 x 2 design where patients were either randomized to concurrent chemoradiation with 5-FU mitomycin C or concurrent chemoradiation with 5-FU cisplatin. But then there was a second randomization after chemoradiation where half of the study participants received adjuvant cisplatin 5-fluorouracil after completion of their chemo radiation, or the other half were randomized to the standard of care, which of course would be observation. And what that trial showed was that there was no added benefit with the addition of post-chemoradiation cytotoxic chemotherapy. So we look at these data and say that in general, for the general population of patients with localized stages I to III anal cancer, there really is no supporting data suggesting benefit of either induction chemotherapy or adjuvant chemotherapy. And to that end, really it's concurrent chemoradiation remains the standard of care at this time for patients with a new diagnosis of localized anal cancer. Brittany Harvey: Absolutely. It's just as important to know what is not recommended as it is to know what is recommended for these patients. And so I thank you for explaining the evidence behind that decision from the panel as well. So then, are there any other considerations for special populations that oncologists should consider? Dr. Van Morris: I think so. I think that anal cancer is a disease where we don't see that many patients being diagnosed earlier at a younger age, especially in relation to the alarming trend of early onset colorectal cancer that we're currently seeing right now. So there may be patients who come with a new diagnosis of localized anal cancer who are an octogenarian at an advanced age or may have other significant medical comorbidities. And if that is the case, we get called about this quite frequently from outside institutions. I have an 85 year old who is coming to my clinic with this diagnosis. I don't feel comfortable giving this patient doublet cytotoxics, what options do I have? Especially given other organ dysfunction that may precede this diagnosis. And I think that in that case, there are times when it's okay safely to drop the mitomycin C and opt for single agent 5-fluorouracil as a single cytotoxic agent. So I think that that would be something that we've certainly incorporated into our practice at our institution. There's also an association between various autoimmune disorders, patients on immunosuppression, even persons living with HIV being at higher risk for this virally associated cancer. So I think that, again, if the patient is coming with baseline immunosuppression for these reasons prior to treatment, certainly kind of being in tune to the potential for hematologic toxicity. And watching these patients very closely as they're getting chemoradiation remains really important. Brittany Harvey: Definitely. So, you've just discussed some of those comorbidities and patient characteristics that are important for clinicians to consider when deciding which regimens to offer. So in addition to those, in your view, what is the importance of this guideline and how will it impact clinical practice for clinicians who are reading this guideline. Dr. Van Morris: Chemoradiation remains a very effective option and most patients will be cured with this diagnosis and with this treatment. So it's important to make sure that these patients are able to safely get through their treatment, minimizing treatment delays due to toxicities which may come about because of the treatment, and really help to carry them over the finish line so that they have the best likelihood for achieving cure. So we really hope that these data will provide oncologists with a readily available summary of the existing data that they can refer to and continue to help as many patients as possible achieve and experience a cure. Brittany Harvey: Absolutely. So then to build on that, it's great to have this first guideline from ASCO on anal squamous cell carcinoma. But how will these new recommendations affect patients with stage I to III anal cancer? Dr. Van Morris: I certainly hope it will allow patients and oncologists to know what their options are. It certainly is not a one size fits all treatment approach with regards to the options which are available. Depending on the patient, depending on the various medical conditions that may accompany them, these treatments may need to be tailored to most safely get them through their treatment. Brittany Harvey: I appreciate you describing the importance of this guideline for both clinicians and patients. So what other outstanding questions and future research do you anticipate seeing in this field? Dr. Van Morris: It's a really good question and I think that there is a lot coming on the horizon. Even though the standard treatment has really not changed over the last half century, I think it still remains true that not all patients will achieve cure with a chemoradiation treatment. So a recent trial has completed enrollment in the United States, this is the EA2165 trial led by one of our committee members, Dr. Rajdev and Dr. Eng as well, that's looking at the use of nivolumab anti PD-1 immunotherapy after completion of concurrent chemo adiation. So in that trial, patients were randomized to concurrent chemoradiation followed by either observation or six months of adjuvant anti PD-1 therapy. We're really awaiting the results of that. Hopefully if we see an improvement with the addition of nivolumab following concurrent chemoradiation, our hope would be that more patients would be able to achieve a cure. So we're certainly looking forward to the outcomes of that EA2165 study. And then I think one question that we often get from our patients in the clinics is, “What is the role of circulating tumor DNA in the management of my disease?” And really, to date there have been some series which have shown that we can assess patients or circulating tumor DNA after completion of their concurrent chemo radiation that may need to start about three months after to give time for the radiation to wear off and most accurately prognosticate that. But I think that this will be a powerful tool moving forward, hopefully, not only in the surveillance to identify patients who may be at high risk for recurrence, but ultimately to translate that into next generation clinical trials which would treat patients at higher risk for recurrence by virtue of a detectable circulating tumor DNA result. In doing so, hopefully cure even more patients with this diagnosis. Brittany Harvey: Yes, we'll look forward to these developments and hope to add more options for potential treatment and surveillance for patients with anal cancer. So, I want to thank you so much for your work to develop these guidelines and share these recommendations with us and everything that the expert panel did to put this guideline together. Thank you for your time today, Dr. Morris. Dr. Van Morris: Thank you. And thank you to ASCO for helping to keep this information out there and ready for oncologists for this rare cancer. Brittany Harvey: Absolutely. And finally, thank you to all of our listeners for tuning in to the ASCO Guidelines podcast. To read the full guideline, go to www.asco.org/gastrointestinal-cancer-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app, which is available in the Apple App Store or the Google Play Store. If you have enjoyed what you've heard today, please rate and review the podcast and be sure to subscribe so you never miss an episode.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement.    

Welcome to Sew & So, brought to you by BERNINA, made to create! I'm Meg Goodman, and today, you're in for an exclusive treat. Join me on a behind-the-scenes tour of a truly extraordinary milestone—the 50th anniversary of the Houston Quilt Festival.  This isn't just any quilt show; it's an international celebration of artistry, creativity, and history. We'll be diving deep with attendees, educators, personalities, and prize-winning quilters, capturing those moments that make this event so iconic. And, of course, we'll be peeking behind the curtains… because that's what we love to do on Sew & So, bringing you right into the heart of the action at one of the world's most renowned quilt festivals. This legendary event began in 1974, a time when the world was changing fast. Karey Bresenhan, a visionary, opened her quilt shop, Great Expectations, in Houston, Texas, sparking what would become an incredible journey. Just to give you a sense of that time: President Nixon resigned over Watergate, ABBA's Waterloo was topping charts, and movies like The Godfather Part II and Blazing Saddles were captivating audiences. Nike was filing its first patent, People magazine launched, and fashion was all about flared pants and leisure suits. Quite a backdrop, right?   The Festival's Remarkable History (1:34)Bob Ruggiero, Vice President of Communications for Quilts, Inc. (www.quiltsinc.com), shares the fascinating story of how the festival began in 1974 and grew into an international sensation. From behind-the-scenes secrets to exciting plans for the future, Bob's insights set the stage for our journey. International Flavors and Creative Innovation (6:31)Meet vibrant vendors like Isabelle Bische from France and Karen Barry of Quilt Passions in Kailua Kona, HI. From Quilts to Mysteries (8:56)Bestselling author Arlene Sachitano (www.Arlenesachitano.com), known for her Harriet Truman/Loose Threads mystery series, explains how Houston inspires her work and why this festival is close to her heart. Stories from Attendees (11:37)Quilters Kim and Jean from Quero, TX, and Becky and Anne from Georgetown, TX, reflect on their favorite moments, while April from Texas and Scott from California share their first impressions of the festival. A Global Masterpiece (13:05)Discover this year's Best of Show quilt, a breathtaking creation from China. Hear from the artist, Chen Jing, in a touching conversation made possible through a friend and Google Translate. Let's let Bob Ruggiero introduce it. Artistry Meets Innovation (17:29)Past Sew & So guest Kestral Michaud (www.kestralmichaud.com) returns as the winner of the Master Award for Contemporary Artistry. Her journey continues to inspire!  Empowering Communities (18:36 & 22:35)Spotlight on nonprofits: Meet newcomers like Danielle Harper from the Barbara Bush Foundation (www.bushhoustonliteracy.org) and Jessica Rudolph from My Very Own Blanket (www.myveryownblanket.org), as well as returning groups like MD Anderson (www.mdanderson.org/ovarian-quilt-project), Sew Powerful (www.sewpowerful.org), and Creativity Shell (www.creativityshell.org). Learn about their incredible missions and how you can help.  Deep in the heart (24:58)In the charming town of LaGrange, TX stands the Texas Quilt Museum. www.texasquilymuseim.org Meet Executive Director Deborah Blanchette Bradley who shares its story and its effort to preserve the history and future of quilting. Why they were there (26:47)Meet attendees April from Texas and Scott from California and they talk about their event experience. Meet Jeanne Delpit of BERNINA (27:42)Making her Sew & So debut, Jeanne (https://weallsew.com/author/jeannecd/) offers a peek behind the scenes of the BERNINA exhibit and her role as National Events Manager.  Rising Stars and Seasoned Pros (30:50 & 34:31)Get to know Nick Jarrett, a newcomer mentored by Ricky Tims, and Uzoma Samuel, who updates us on his artistic achievements since QuiltCon.  Serging Queen and Quilting Royalty (34:58)BERNINA's Pam Mahshie (@pammahshie) and Toni Smith, a.k.a. Quiltoni (www.quiltoni.com), share their latest projects and Houston experiences.  The Magic of Haute Couture (37:52 & 41:19)Fashion visionary Joe Vecchiarelli (@joevecchiarelli) who has many collaborations with Disney, Dancing with the Stars, and Dolly Parton, tells us what he's been up to lately.(40:22) And then there's the wonderful “Evening of Style with Nick Verreos” that Joe was responsible for making happen… An Evening of Style (41:19)And then…there's Nick himself! www.nickverreos.com(46:32)Join us now in the front row for this amazing display of Haute Couture as Nick Verreos provide commentary on his wonderful creations. Here's Jill Benge to lead off the evening!  And the Winners Are… (48:41)Meet the three winners of the BERNINA machines raffled off at the fashion show Kim GImblet, Wendy Shapiro, and Elizabeth Martin  Reflections (49:49)And what did Beth from Pittsburg, Kathy from Prescott, AZ and Lynn from Colleyville TX think of the show?! A Grand Finale (50:37)Bob Ruggiero wraps up the festival with his reflections on this momentous event.And it's this very spirit—the connections, the creativity, the shared passion—that makes the Houston Quilt Festival so extraordinary. We at Sew & So were honored to be right there on the floor, immersed in it all. Our deepest thanks to everyone who shared their time, their stories, and their enthusiasm with us, painting a vivid picture of what makes this festival a cherished experience year after yearBe sure to subscribe to, review and rate this podcast on your favorite platform…and visit our website sewandsopodcast.com for more information about today's and all of our Guests. That's S E W A N D S O Podcast.com. Be sure to subscribe to, review and rate this podcast on your favorite platform…and visit our website sewandsopodcast.com for more information about today's and all of our Guests.

HOST: Hildy Grossman, CO-HOST: Jordan Rich GUESTS: Carl Gay, MD, MD Anderson, Misty Shields, MD, Ph.D., Indiana University Simon Comprehensive Cancer Center. Hildy shares her experience of losing a friend who was diagnosed with neuroendocrine tumors of the gastrointestinal system. Knowing that neuroendocrine cells are present in the lungs prompted Hildy to wonder if lung … Continue reading Size Matters! Small Cell Neuroendocrine Tumors Pack A Mighty Wallop →

This might explain why Medicare Advantage plans are losing their support. More former supporters from each side of the aisle are wavering. The Wikipedia entry for Medicare makes the point that the public expresses more support for government programs that are universal than those that are means tested. MD Anderson, in Houston, has failed to come to agreement and will not remain in Medicare Advantage networks of the Texas Blues. Thanks to a security breach and the evil HIPPA legislation, about one million Medicare participants will be getting new cards with new identifiers (numbers). Finally, I was able to view graphs illustrating the dramatic effect that inflation has had on the premium rates of Plans G and N. Too bad those poor victims weren't enrolled in the High Deductible Plan G (HDG) plans touted by Medicare for the Lazy Man!   Contact me at: DBJ@MLMMailbag.com (Most severe critic: A+)   Inspired by: "MEDICARE FOR THE LAZY MAN 2024; Simplest & Easiest Guide Ever!" on Amazon.com. Return to leave a short customer review & help future readers. Official website: https://www.MedicareForTheLazyMan.com.

Join Ed and macroeconomist Patrick Cox as they discuss demographic reversal, the collapse of Social Security, and rapid advances in longevity medicine, including compelling age-reversal research coming out of Johns Hopkins and MD Anderson.

Welcome to another episode of the Oncology Brothers podcast! In this episode, hosts Drs. Rahul and Rohit Gosain dive into the recent approval of Durvalumab in the perioperative settings for non-small cell lung cancer, based on the AEGEAN trial. Join us as we welcome Dr. Sandip Patel, a medical oncologist from UCSD, and Dr. Mara Antonoff, a thoracic surgeon from MD Anderson, to discuss the implications of this new treatment option. We explore the study design of the AEGEAN trial, its differences from other trials like Keynote 671, and the importance of a multidisciplinary approach in managing lung cancer patients. Key topics include: •⁠  ⁠Overview of the AGEAN trial and its findings •⁠  ⁠The significance of neoadjuvant and adjuvant therapies •⁠  ⁠The role of surgical evaluation and molecular profiling •⁠  ⁠Insights on patient selection and treatment strategies As we shift towards more perioperative and postoperative treatments, understanding the nuances of these approaches is crucial for optimizing patient outcomes. Tune in for valuable insights and discussions that can help shape your practice! Don't forget to like, subscribe, and hit the notification bell for more episodes on recent approvals and practice-changing data in oncology! #OncologyBrothers #LungCancer #Dervalumab #AEGEANTrial #MultidisciplinaryCare #MedicalOncology #ThoracicSurgery Website: ⁠http://www.oncbrothers.com/ ⁠ X/Twitter: ⁠https://twitter.com/oncbrothers ⁠ Contact us at info@oncbrothers.com

In this episode, we welcome Shalini Yadav, a 2024 Executive MBA graduate and visionary leader in the field of synthetic biology. With over 22 years of research experience, including a decade in leadership, Shalini has a deep expertise in synthetic biology, immuno-oncology, and therapeutics. She now serves as the Executive Director of Rice's Synthetic Biology Institute, where she spearheads cutting-edge research, fosters interdisciplinary collaboration, and drives the institute's mission to unlock synthetic biology's transformative potential.Host Maya Pomroy '22 speaks with Shalini about her inspiring journey from growing up in Allahabad, India, to leading translational cancer research at MD Anderson Cancer Center in Houston. Shalini reflects on how her early experiences with infectious diseases and her education, from New Delhi to Stony Brook University, shaped her passion for synthetic biology. She also shares her thoughts on the field's potential to revolutionize science and the critical role of integrating business strategy into scientific innovation.Episode Guide:02:39 Early Life and Education04:13 Challenges and Adventures in the US07:08 Groundbreaking Research and Discoveries10:00 Transition to Translational Research14:23 Journey to MD Anderson and Houston17:17 Why Pursue an MBA Now?27:16 Synthetic Biology: The Next Scientific Revolution37:48 Future Aspirations and ConclusionOwl Have You Know is a production of Rice Business and is produced by University FM.Episode Quotes:How a serendipitous opportunity brought Shalini to Houston14:09: [Maya Pomroy] So what brought you to Houston? Was it MD Anderson that brought you to Houston?14:35: [Shalini Yadav] When I got an opportunity, again grateful to the PCF Young Investigator Award that I got, this network of people that I met, and through that, I was able to connect with Dr. Allison, and it, again, serendipitously, happened that he, looking at my expertise and things that I had done, said, “Would you like to do this work, which is a lot of scientific management and administrative?” [15:06] I thought, okay, as long as I found it interesting and exciting, because, again, I was handling multiple stakeholders and trying to work with multiple pharmaceutical companies, different departments, different kinds of experts, working together with all of them to handle a scientific problem, which will actually help to learn something new. So that was very satisfying to do that.How an MBA gave Shalini a new perspective on impact32:42: I would like to say that scientists in general are passionate about what they do. It's the leap that you have to take that overcome, and your perspective changes after MBA. I never had this perspective. The way I understand things now are completely different than I would have done two years back. 33:18: So if community matters to you and if you're bothered by things around you, which you want to change and you think with this you cannot. I think taking that leap where you will learn things, which I think basically as a scientist, our training as graduate students, or even medical studies, we are taught to be very focused. So having to come out of that shell and embrace this bigger picture and having the strength to think about what impact I can have because if you understand both sides of it, what you can think of achieving, you won't get it if you are just on one side of things. The effect of bridging the gap between clinical and translational research and basic research11:35: When you bring diverse expertise together, the solutions that come out have way more value and are more impactful than what you can achieve alone. So bridging this gap was not something that I was looking for, but I serendipitously got into a position where I just did what was needed, which gave me a very different perspective of what scientific research can achieve in terms of, if you understand the problems which people are actually facing, then your solutions can be tailored, or you can design proposals to address those problems.Show Links: TranscriptGuest Profiles:Shalini Yadav | LinkedInRice Synthetic Biology Institute MD Anderson Cancer CenterYoung Investigator Awards | Prostate Cancer FoundationWorld Health Organization Catch our previous episode with Jillian Lebovitz Fink: "A Former Fourth-Grade Teacher Is Working to Ease Your Migraines." Listen now: https://business.rice.edu/owlhaveyouknow/season-3-episode-16

In this episode of Building Texas Business, I learned how a missed home run sparked the creation of Rivalry Tech from co-founder Aaron Canopy. He conveyed the early challenges of building their platform from the ground up and initial launches at Rice University football games. Aaron discussed their pivotal strategic partnership with Aramark, which led to expansion into major league venues like the Mets, setting them up for scalable growth. I also discovered how the company used the COVID-19 pandemic to refine its software and form industry relationships. Additionally, the importance of building a dynamic culture centered around transparency, open communication, and employee empowerment was highlighted. Strategic collaborations with Comcast Business assisted in entering new verticals. Aaron provides insightful entrepreneurial lessons through strategic partnerships on values like self-funding phases, team building, and innovation. SHOW HIGHLIGHTS In this episode, I interview Aaron Knape, CEO and co-founder of Rivalry Tech, about his journey from a missed World Series home run to founding a successful food delivery technology company for sports and entertainment venues. Aaron discusses the initial inspiration for Rivalry Tech, which came when his partner, Marshall Law, missed a crucial home run while waiting in line for food during a 2017 World Series game. Aaron and Marshall, neither of whom were tech experts, navigated numerous challenges in the early days, including finding the right tech talent and building a minimum viable product with the help of Craig Zekonty, a former Rice MBA classmate. The episode explores how Rivalry Tech started at Rice University football games and eventually expanded to other venues, including a significant partnership with the New York Mets. Aaron shares how the COVID-19 pandemic allowed Rivalry Tech to focus on fortifying their software and establishing key industry relationships, ultimately positioning themselves for scalable growth. The importance of strategic partnerships is highlighted, including collaborations with Aramark and Comcast Business, which have helped Rivalry Tech expand into new verticals like healthcare and hospitality. Aaron emphasizes the significance of company culture at Rivalry Tech, which includes transparency, open communication, and fostering an environment where employees feel empowered to voice their ideas and criticisms. The episode delves into the lessons learned from strategic partnerships, including the necessity of validating customer needs before development and anticipating market trends. Aaron discusses his philosophy on hiring, emphasizing the "hire slow, fire medium fast" approach and the value of team loyalty during tough times. The episode concludes with a glimpse into Aaron's personal life, including his preference for Tex-Mex over barbecue and what he would do on a 30-day sabbatical. LINKSShow Notes Previous Episodes About BoyarMiller About Rivalry Tech GUESTS Aaron KnapeAbout Aaron TRANSCRIPT (AI transcript provided as supporting material and may contain errors) Chris: In this episode, you will meet Aaron Canopy, CEO and co-founder of Rivalry Tech. Aaron tells a fascinating story about how missing a home run during the World Series led to he and his partner creating a successful technology company in the food delivery industry. Aaron, thanks again for taking time. Welcome to Building Texas Business. Aaron: Yeah, great to be here. Thanks for having me, Chris so let's talk about Rival would use to order the food. And it's our software and it's our hardware that's back in the kitchen, that lets the people back there get that food out faster. So, known for sports and entertainment, we're now in healthcare, fast food, restaurants, hotels, resorts, casinos, wow. Chris: So kind of like the Amazon Prime of food delivery. I think so yeah, it is, I like that. So what was the inspiration to start the company? Aaron: Yeah, so my partner Marshall Law. Actually his full name is Jesse James Marshall Law no way, no joke. Chris: Yeah, that's his real name. Aaron: Parents are comedians. They must have been. Yeah, they're awesome. But he was at Astros-Dodgers World Series back in 2017, sitting out in the left field and ran up to get a hot dog and a Coke with his two boys, and while he was up there waiting in line for 20, 25 minutes, yuli Gurriel just hits a bomb and it's right over his seats and you can go back to the highlight reel and you can see Marshall's empty seats. So he's crushed, right, he's devastated, and that's the whole reason you go to an Astros game to see moments like that. But it was even worse that it was right over his seats. So he texts me that night and says man, we've got to fix this. We've got to like why is there no app for food delivery in a stadium? And so that's when Rivalry Tech was born. Back then we called it seats, but that's when it was born. Chris: Oh, we don't, yeah. So a lot of people start companies where they see gaps in a process or something. Aaron: Yeah. Chris: But that was pretty remarkable. I mean literally leaving the stadium. He sends you a text about this. Aaron: He did and he was adamant. You know my being, you know, skeptic in general. I was like, well, either it's already being done or it's not efficient to do in a stadium. And he said, well, it's got to be done somewhere, so we're going to do it. It's going to be you and me, and he's very charismatic. So he convinced me to join up with him and we started the company a couple months later, Wow so walk us through that then what was it? Chris: you know what was it like and kind of what were the missteps taken to kind of start from scratch on this kind of idea that born out of frustration. Aaron: Yeah, yeah, you know that neither of us are tech founders, right? Neither of us are tech guys. So we had another hurdle to cross. You know, marshall had done some internet research and found you could build an app for $3,000. And we laugh to this day we look at the millions of dollars we've spent on the platform. So we might have been a little fooled into thinking it was going to be easier than it has been. But we started by, you know, trying to understand what the real need was, trying to just kind of map it out. And then we had to find a tech guy who was going to build this for us, right, because Houston's got a lot of tech talent now, a lot more than it did seven years ago when we started the company. But seven years ago it was tough and all the tech talent was being utilized by oil and gas and healthcare. You know, it's not like the West Coast where you've got a lot of talent. So we set out to find tech talent and that's where I went to. One of my old rice MBA classmates got in Craig's a canty who I knew had been a developer in his past life. He had his own successful company called Pino's Palate that he had built and grown and scaled, and so I said, hey, help me find a tech guy. And so we looked for two, three months and finally Craig comes to me and he says I found him, it's me. So great. Aaron: So Craig got back into startup life and that was probably one of the best things that happened to us, because he's very organized, very methodical and he's not just a coder, he's an architect, and so we got really lucky early on that we weren't like a typical tech startup where we're just writing code and it's kind of all thrown together. We were building enterprise grade, minimum viable product in the early days, right. So we kind of had a leg up in those early days and Craig is also co-founder, so he joined the company, really helped us get it off the ground. And then we went to work. We went to work and started out at Rice University football with our wives handing out flyers, our kids and brothers and friends were delivering the food into the stands and I was running a laptop just manually assigning orders and it was definitely a minimum viable product back at the time. But Rice had faith in us and we did them right and delivered a good first product and we learned a lot from that experience. Wow. Chris: So yeah, and it's grown from there. Aaron: We've grown from there. We then went, we got the Skeeters now the Space Cowboys to sign up with us, right, and then we had our big break. Then we got really lucky. We're building software the whole time, we're learning from Rice and Skeeters. And we had really good opportunity to be put in front of one of our old mutual friends, jamie Roots oh, sure, and president of the Texans at the time, and it was at a pitch event and it was funny. I'd never met Jamie. I didn't know him prior to this and he was sitting in my chair at my table at some point and I didn't recognize him. And I walked up to grab my bottle of water and Marshall's wife, melissa, knows him and she said, hey, aaron, this is Jamie. And I'm like, hey, what's up man? And she goes no, this is Jamie Roots. And I'm like, oh. And so we had a great 15-minute conversation and he said, man, I really like what I'm hearing. I like your ethos, I like the aggressiveness. We have an issue with the fan experience at NRG Stadium. I want you to come down and meet with Aramark and let's give it a go. So he got us into the stadium and I remember walking in and meeting with Aramark and Jamie and I won't name names. But the Aramark guy walks in the in the boardroom and he sits down and he goes mobile ordering is BS. It'll never work at scale and in stadiums. And I thought, man, we're done, yeah, we're toast. And Marshall leans across the table and says, well, that's because you're doing it wrong. So we got a kick out of that. They gave us a shot and we did well. We had a few thousand seats we were serving. We showed them that it could be done logistically, we could make money off of it and that we had a good product. So from there we started to scale and and built a really good relationship with Aramark, one we maintain to this day. And you know the sports side. We work with them at other pro stadiums. We work with them at Minute Maid. Right now we work with them at Fenway Park. The Boston Red Sox, the New York Mets. Those are some key Aramark partnerships with us. Chris: Wow, that's a great story, fortuitous, like most, if you're working hard and you get that lucky break and take advantage of it. The combination of hard work and luck sometimes is a really good thing. Aaron: It is. It helps, and we were astute enough at the time to understand that there is a bigger problem. The bigger problem wasn't that a fan wanted a beer or a hot dog in their seat their seat. It's that the operators the arrow marks of the world were having trouble keeping up with that unfettered convenience. We'll call it right, okay. All of a sudden, you go from lines, which naturally throttle your demand, to cell phones and everybody can order as much as they want, whenever they want, and they all expect it to show up in two minutes. So we learned that the operational challenges were the real problem and that's where we turned our focus. So now, when you look at our platform, it's not just about delivering food, it's about streamlining that entire process. Yeah, if the kitchen can't keep up, then it doesn't matter. Right? That's exactly right. Yeah, that's exactly right. So building in the controls, the throttles, the reporting, the communication, all that stuff's baked into our platform. Chris: So a couple of things that come to mind as you talk about what sounds like a lot of focus in Energy One on product development, software and then trying to prove the concept. What did you all do to try to finance that? Did you have to go out and raise money? Were you doing it yourself? Because most startups and entrepreneurs face that conundrum and there's a number of different ways to handle it. Aaron: What did y'all do at Robbery, at the beginning we were self-funded, we were self-financed, we were bootstrapping it. I had a good job. I was president of a manufacturing company. Marshall has like three, four other companies, he's a serial entrepreneur and Craig was running Pino's Pallet. So we all had good jobs and we were able to fund the beginning parts of the company and ultimately it got to a point where really two things happened. One, I was spending more than 40, 50 hours a week on rivalry tech, and we saw that we were getting enough traction that it needed full-time focus, and so as a group we decided, okay, it was time for one of us to leave, and that was me. So I left my job and we financed a salary to get it going and do some fundraising, and we raised our first round of funding from Venture Capital probably about a year into operations, when we really wanted to start scaling, and that was interesting as well. That was a fun experience, but now that's how we got it started Just a lot of sweat, blood, tears and a lot of our own money. Chris: Yeah, that's a common theme for anyone kind of starting something from the ground up. Aaron: Yeah it is, and it's interesting when you do it that way, and I'll give credit to know when you have an idea and you want to start a company. You've got about a thousand ideas. Here's what it should be, and Craig was really good at saying, ok, but we can only afford to build three of those things out of the thousand things. What are the three things we really need to prove? What's going to help us get to that next round of funding or what's going to help us get that next customer? And it's not all the super convenient stuff right. It's not about sending you a text message when you're within a mile of the stadium. That's not going to generate revenue. So we really had to spend time and figure out what are the most most important things to build, and that's how we got the first version of the platform out right. We just wanted to prove that, a people would use it. B people would spend money to use it. And C we could help the customers make more money. And that was it right. So that's how you get to a platform where you have to have your kids deliver food. Chris: I'm sure that was great. Yeah, they enjoyed that a bit. They did, they had a blast. So then you know, the next, I guess, issue you face, I'm guessing is, as that success is coming, you've got to start building your team to service the customers that you're bringing in. Yeah, how did y'all go about doing that and kind of going through adding key people in the right spots at the right time? Aaron: You know that was a really interesting journey for us. You know, at the beginning we knew it was mostly about tech, like we had to build the technology and the software. We did hire an operations guy in January of 2020. It was a great time to hire a field ops guy, no-transcript. And so you know, at that stage we were really trying to figure out where we scale and how we scale, and we got to go hire all these operations, people et cetera. But then something happened in March of 2020 that changed the course of live sports and entertainment. Just a little bit. Chris: Right. Well, our good friend Jamie. I remember him saying at the time it's a terrible time to be in the mass gathering business. Aaron: That's exactly right. So you know, when COVID shut everything down, it was really funny we were actually in an investor meeting. It was, I think it was March 11th, 2020. And we're talking about raising a series A and we're going to raise some more money, and then the phones kind of start buzzing and vibrating and everyone's looking down and they're like, oh man, the rodeo just canceled and or just shut down. And then a few minutes later it was like, oh, the Rockets have postponed, you know, their season already. And or no, it was the Astros. I'm sorry, the Astros postponed their season, start dating all of this. And so we said, okay, well, maybe we shouldn't have this investment meeting right now. And that really kind of set the stage for, quite honestly, was a better growth phase for us, and I actually give COVID not that it deserves any, but I give it credit for turning us into the company we are today. We took COVID and took that time to build the software we really wanted to build, if that makes sense. So, rather than splitting resources you know we had precious resources at the time rather than splitting it between operations and marketing and all the other things you're normally spending money on, we put it all into tech and by then we had established a good relationship with Aramark. We had established a good relationship with the teams like the Texans, like the Astros, and we had established a good relationship with Major League Baseball through some of our other connections at Aramark. And so we just spent all that time in isolation talking to these other people who were in isolation. So, mlb, they became really good, almost friends, and said here's what hasn't been built, here's why you don't see it at every stadium. And we listened, and so we somehow managed to raise almost $2 million during COVID throughout 2020 and just put it all towards the software Wow. And so we were able to come out of 2020 better funded, but also with a product that MLB signed off on it we launched at the New York Mets in 2021, coming out of COVID. So that really helped us allocate those tech resources and then we could start. And, if you think about it, covid also gave us a really nice kind of gradual increase in activity with operations. So we hired one ops guy, because ballparks are only at 10% capacity, sure, and they were at 30, then 50, and then 100. So we were able to scale. It was a lot better runway than just getting hit with it all at once yeah, I guess it makes sense right. Chris: You were able to kind of that hiring process that we kind of started talking about you were able to ease into that right and not have to throw a lot of investment at it because of exactly the ramp up exactly and we were able to take our time and find good people. Aaron: You know, culture is huge for us. Startup life is a grind. Startup life in live sports and entertainment is probably worse because it's a lot of nights, it's a lot of weekends. It's going to happen, whether you want it to or not, you know. I mean, the schedule is the schedule and so we had to find those people who, you know, kind of thrive on that life. They like going and the insanity and the chaos around. You know, trying to serve food to 80,000 people, you know, on any given Sunday. Chris: Oh, I can't imagine right. The other thing, though, that you know, I hear from your lessons and the advantages you took during, you know, kind of the COVID shutdown, if you will, was you really and this applies at any time but the importance and value that you gain by listening to your customer? And we have what were the issues, what did they like, what would they change if they could? And then you were one listening and you took that back to the developers or maybe they were in the meeting too to make those adaptations and modifications. Aaron: Yeah, yeah, exactly. It really helped highlight a lot of those bigger challenges right, where we got to understand, okay, well, we did have the good fortune of working through Texan season in 2019 and we saw the issues, and then COVID just allowed us to sit face-to-face from the customer when they weren't distracted, when Aramark and the Texans weren't distracted by the season. They're just sitting at home literally and let's talk through it and we're going to build it for you guys. So, yeah, it really helped put a magnifying glass in without the chaos, and that made all the difference, right, because we have a lot of competitors who just build on the fly and they're just trying to build and learn and they're getting beat up every day and that, and they're getting beat up every day and that's the advantage we have. Chris: That's great. Advert Hello friends, this is Chris Hanslick, your Building Texas business host. Did you know that Boyer Miller, the producer of this podcast, is a business law firm that works with entrepreneurs, corporations and business leaders? Our team of attorneys serve as strategic partners to businesses by providing legal guidance to organizations of all sizes. Get to know the firm at boyermiller.com, and thanks for listening to the show. Chris: Well, you mentioned culture, and I definitely don't want to gloss over that. Couldn't agree more. I mean, culture is everything. What have you done at Robbery to build the culture that you appear to be proud of, and how would you describe that culture? Aaron: with grit. I mean a lot of people use that term as part of their core values, but for us it's. We really make sure, whoever sitting across the table, they know that this isn't an eight-to-five job, that this is going to be some nights and weekends and you may have a thought at 2 am and you know Marshall and I talk at 2 am all the time. We don't expect that from everybody, but hey, just know that you don't have to answer that 2 you in text, but if you want to, that's okay. But we've got a really fun culture. I mean, look, first of all, we're doing a lot of fun things. I mean whether we're at sports or, you know, I mean resorts. We do the Margaritaville up in Conroe. I mean there's worse places to go to have to do work, right. I mean we even enjoy going down to the hospitals. We're at Methodist in the Med Center. We've got some robotics stuff. It's just a lot of fun. And it's really fun to go into areas where, you know, people aren't using a lot of technology on the food and beverage side, and so we really focus just on people who are creative and they like to question and they like to come up with answers or solutions, you know we don't have. We try not to have any of those barriers where they feel like they can't approach me with an idea or criticism or feedback. You know, I think part of our success has been allowing everybody in the company to have a voice and there's no such thing as a stupid idea or a bad idea. You never know where it's going to go right, and so you know we like that everybody can feel safe just throwing it out there, right, I mean? And we've had some crazy ideas come across the come across the whiteboard, and some of them have gone on to become parts of the product and some we've tucked away and some we've giggled at and erased, you know yeah. And then we've got definitely a culture of you know, just a very candid culture, right? I'm trying to think of what the phrase is, but our candor is very important. So, you know, we have a lot of meetings where we'll share ideas and opinions and then we'll fight about those ideas and opinions and voices will get raised and pulses will increase and language will be thrown around. But at the end of the day, everybody does it respectfully and you can scream and yell at your partner all you want, but we always make up and we realize it's coming from a place of trying to better the company. Chris: Yeah, Sounds like transparency, but also in a safe environment, right. Aaron: It is. Chris: Yeah, the other thing that sounds like you've created within that culture is one that fosters innovation you talked about. People are encouraged to bring their ideas to the table. Yeah, their ideas to the table? Yeah, how? I mean? Are there things that are meetings you have to, or challenges you present to people so that they know that innovation is respected and welcomed? Aaron: Yeah, we do. I mean we have weekly meetings where we kind of go through everything from the tech roadmap to the operational roadmap to sales and marketing, and we just talk through what we're seeing in the market, try to identify the gaps, right. So we're really trying to teach everybody in the company look for those gaps. Where are we seeing, you know, areas where there's no solutions? And so I mean we love whiteboards. I mean if I could have every surface in the office be whiteboard, it would be whiteboard. I mean, put it up on the whiteboard and go and let's start playing with it. And we've gone through some sessions where we've covered a whole room and come up with new ideas or better ways to execute. Right, I mean we're dealing with, you know, a stadium or a hospital. They're not simple organisms, they're very complex. And then when you get back into the food and beverage service side and fragmented technology stacks that they're using in the back and how do you tie it all together? And then you got to pull in the different stakeholders the hospitals, the aramarks, the employees. It becomes a lot of moving pieces and within that is opportunity, yeah, and so we spend a lot of time just talking through you know where and how can we do this? Chris: so let's let's talk a little bit about you. Know you start in sports missing the home run of the World Series. You mentioned this and alluded to it earlier. You've grown in sports. While you still do. That's not your primary area. Tell us a little bit about you. Know how you moved into health care, as an example. Aaron: And what are some? Chris: of the innovative things that you're actually doing, that when people show up, you know hopefully not at a hospital, but at a resort or or something that they could see to know that this is your technology in play. Aaron: Yeah, so sports and entertainment was our focus market for a very long time and we realized that the needs existed everywhere. Right, the problem that we were solving wasn't just at large stadiums, so large operators like Aramark, they operate in a whole host of other industries, right, like we talked about hospitality or leisure hospitals, etc. And so we knew we wanted to expand into those other verticals at some point. And we got really lucky again where and you can obviously tell Aramark's been a great partner throughout all this Right, they called us out of the headquarters up in Philly and it was really funny. I'd gotten to know the guy well and he says, hey, great job in sports, you've solved a lot of issues for us. You've built a great platform. Can you do it in other business verticals? Could you do it in health care? And we said, absolutely, yeah, we've been wanting to for a long time. What are you looking for? And he goes well, we've got a customer down in Houston and you can hear the papers kind of flipping through. You ever heard of MD Anderson? Yeah, yes, I've heard of MD Anderson. He goes. Yeah, they have a need down there. We want you to go look at it, and so worked through some of that. But what ended up happening is we actually got in front of Houston Methodist and their innovation team is really great, really employee focused, really patient focused. But they wanted us to focus on putting in our mobile platform for the employees because you think about it a doctor or a nurse, 30-minute lunch breaks you don't want them waiting in line for 15, 20 minutes, right. So we saw that as our opening. We knew we wanted to expand here. We have a customer pulling us into this other market, right. So that's how we got started. We built the platform for hospitals at first, but the really cool thing about it is that that same platform applies to every other market in the world, right? Sports is unique. It's a four-hour event, five-hour event. You turn it on, you turn it off. A day or two, a couple days a week, depending on a baseball home stand football once a week, exactly, but a hospital, a hotel, fast food, I mean 365 days a year, sometimes 24 hours a day. So we built this new platform for them. And let's use Houston Methodist as an example. So we've got our mobile at all. And let's use Houston Methodist as an example. So we've got our mobile at all eight of their locations in Houston. We have our kiosks at all eight of their locations, so you can walk up to a coffee shop, order a coffee at one of our kiosks and the barista will make it. You don't have to wait in line and then we're doing some really fun stuff. So, like in the Med Center, we are integrated with a big robot made by ABB Robotics, and this thing makes your food from fresh ingredients to. It actually cooks it, it puts it in a bowl and puts it in a locker for you. That robot didn't have any way to communicate with the guest or for the guest to communicate with the food preparation system, right, which normally is a person behind a counter you talk to Right, and it didn't have any way to communicate with Aramark in the back. Hey, here's the reporting for the day. Here's what I've made. Well, we do all of that, and so we essentially said look, just let's and to oversimplify, just run a line from the robot into our platform and we'll take care of the rest. And that's what we we did. So you can order food from our app and the robot will make your food. It'll tell you when it's ready. It'll tell you what locker it's in. You walk up and you scan a little code we give you, and your locker just opens up, and then we do all the reporting for the customer at the end of the night as well, so they can see what you know delivery or make times were, etc. Now we're getting into delivery. Robotics have the just, so we're controlling that order fulfillment process again from the very beginning to the very end, right, Whether it's a human or a robot. So it's pretty fascinating. Chris: Sounds like I'm still trying to wrap my head around a robot cooking in the kitchen. Yeah, it's pretty cool. Aaron: It's their induction cookers. They look like concrete mixers and so it's tossing these, this pasta or this chicken, and like a concrete mixer and it's cooking it. So it's pretty neat. That's amazing. Chris: So you know clearly. You mentioned AeroMark several times and, based on the story, I can see that they're a key strategic partner for you, as are some others. What are some of the advice you could give others about how to cultivate those relationships that are so central to your business? Aaron: So I mean, Aramark was an obvious one for us in the early days because they were the gatekeeper to a lot of our stadiums. And the other part of that is we knew we didn't want to go door to door knocking on different stadiums' doors. They are in hundreds of stadiums, so build for one major customer, make them happy and they'll sell for you and they'll take you along right, and they'll take us along. That's exactly right. So we were very intent and strategic on a relationship like that and we've worked with Aramark's competitors as well. We work with a lot of them and it's that same mentality, right. But then, you know, we started looking for other partnerships and this was a really interesting one where Comcast Business, comcast Sports Tech, has, or Comcast Business has, a sports tech accelerator and we were asked to join a couple of years ago and we thought we might have been a little too big. We said, well, we've grown, we don't know that we need a tech accelerator. But they said, look, we're trying to give our partners in the space some more developed platforms and their partners are like PGA Tour, wwe, nascar, and so we signed up with. But we were very upfront with them. We said sports is not our focus market anymore. We want to work with Comcast business and they came back to us and said absolutely We'll intro you to the mothership big Comcast, join our sports tech accelerator. So we did, and great relationships out of that right We've. We now work with PGA Tour. We've got some agreements with them, working with them in a few locations, but Comcast Sports Tech did exactly what they said they would and I'll respect them forever for this, because you never know, right, like, do they really have any pull with the mothership Whatever? And so we are now fully ingrained in the Comcast business and what's called Comcast Smart Solutions, where they sell internet right, they sell connectivity and it's a commodity, but what they're using us for and a few other companies are where the value add wrappers right. So we're working with an NHL team. Right now Comcast is going to provide the Wi-Fi, the access points, but hey, guess what NHL team? We also provide mobile kiosk back of house software. There's other companies doing digital signage, iot, and so now they've got this whole ecosystem that they're taking out to their customers and we work with them, not just pro sports, but major franchise chains with 30,000 restaurants, more major hospitals, hotel chains with thousands of hotels, and so now we start going in and we've got this really strong partnership with a major player. And they had a lot of people knocking on the door and we just took the same approach Build, listen to them first, build what they want, build what their customers want, and they'll take you wherever you want to go. So that's great. It's not without its challenges, right. It's a slow process. You're building something for a multi-billion dollar company like a Comcast or an Aramark. You don't get sales overnight. You've got to dig in and you've got to understand that it's going to take time and investment. But when that flywheel gets spinning it's sure hard to slow down. Chris: Yeah, that's great, yeah, but you're right. I mean we talk about it. It doesn't happen overnight. You've talked maybe a little bit about it, but I think we also learned. I'm sure there were some mistakes made, setbacks that you and your team learned from. That also helped you later become as successful as you have been 100%. Anything that comes to mind that stands out as one of the bigger ones. Yeah. Aaron: You know, in software it can be challenging because people, customers, will just say, hey, I want this, I want it to do this, and the proper answer is do you really need it? Do you really need it to do that Other than a? Chris: programmer going sure, I can do that, yeah, and they will right. Aaron: And you could spend all the money you want. And I remember this isn't a major mistake, fortunately. But I remember we were at an NFL team and it was a customer and they said we want the ability for the app to, or the users to, pay with cash. And we're like why do you want to pay with cash? We're digital, we don't need, and they're like we have to have it. You have to have the ability to say this was a cash payment and then reconcile the end of the night. And we were like and this was a week before the season, and so we hired a couple of extra developers, we spent I don't know 50 grand to add this cache functionality. And we go back a week later and we're proud of it and we're like check it out, and you know what the team said oh man, we decided afterwards we didn't need it anyway. I wanted to strangle them. Aaron: I was going man, we jumped through hoops. You could have told us, right, yeah, you could have told us, like, when you decided you made the decision, but here we go and we built it. So you know, in the early days of a company you're really eager to please and you do have to kind of take a step back and say, look, we can't build it all, you'll go broke or you'll build need and you'll never use. That goofy function is still sitting out there somewhere attached to our platform, right just turned off, yeah like an appendix right. We don't need it and it's just there forever. That's probably one of the biggest things we learned in the early days. You know we've learned as well that I mean you've got to keep your head on a swivel for new developments in the market. You've always got to be looking at what's coming down the pipeline. You know we probably erred a little bit and not getting into kiosks earlier. When COVID hit, we thought no one's going to, no one wants a kiosk, they don't want to touch anything. Right, remember the early days we were fogging everything and the reality is kiosks are probably the biggest thing out there right now and it's a natural extension of our platform. We had the time to do it and we're getting in the game and getting in the game a good way and you know, to be fair, it's we're not worried about that first mover advantage. We've got a lot of mistakes from our competitors that we're learning from and gaining ground very quickly. But you do learn to start looking farther down the road. Right, we were maybe looking a year down the road. You've got to be looking two years down the road. What's really coming down? So now, if you look at what we're focused on biometrics, computer vision there's a lot of components that are on our roadmap or on our current integrations that we're building, that you won't even recognize our platform six months from now. Chris: Wow, that sounds pretty cool. Yeah, it's fun. So while we have some time, let's turn and talk a little bit about leadership. As you said, you kind of were the first to really step in full time. You were running a company before. How would you describe your leadership style and why do you think that style has been successful in helping Ravelry grow to the company? It's been. Aaron: Yeah, we like to hire people who take a lot of initiative on their own, who aren't afraid to go out and do something and maybe make a mistake and try it again. So you know, in the startup world or in the tech world there's a and this applies to a lot of places but you know it's hire slow and fire fast. And we hire slow and we'll fire like medium fast. You can't make everybody think they're going to get fired for making a mistake. My leadership style I'm not a micromanager. I very much. When we hire people, I say look, I'm not going to give you a book to tell you how to do your job. We're going to write this book together because we're breaking new ground every day and we're learning something new every day and I'm not going to pretend to know everything. So I'm hiring you because you're smarter than me. Hopefully. You're known for what you do and do it well. And if I'm going to teach you anything, it's going to be how this company operates and where you can find your best fit and your best purpose. You know, if it's a salesperson, where and how do they make their best fit as a salesperson. You know, if it's a salesperson, where and how do they make their best fit as a salesperson. So you know, that's been my style it's give them some autonomy, give them some ability to go out and make it their own and if you hire slow, you've got a good feel for the person, you know what they're going to be capable of and if you're comfortable with them. So that's how I've tried to lead the company. We've got you know, it hasn't always worked we've had people come and we've had people go. And then we've got some people who, just, you know, they grind it out every day for this company and they're always thinking of new ideas and their days. You go, man. You know when is this guy going to leave me? He's so good, he's bound to go find something better. And they don't and they stay and and I think that speaks to the culture and the loyalty and the environment that we've built- Well, that's certainly true, especially for those high performers. Chris: If they're staying, the reason they're staying is because of the team that they feel like they're a part of, which goes to the culture. Aaron: It does. Yeah, it does, and I'll share a little bit more on the intimate side. We're a tech company, right, and you have your ups and your downs you always do and teams come, teams go, covid happens, covid goes away. We've been through times in our history where we, you know, you're strapped for resources, you're strapped for capital, right, because you're raising venture dollars, sure, and we've let people go who have said can we work for free, like, can we still keep doing our job? We know you can't, you know, afford to have this big team. And you know, I mean I get emotional when I think about that. Sure, that we have people and it's been multiple people who've done that and you bring them back. And the goal is to bring them back. And I mean you can't buy loyalty like that. No, that's not something money buys. And so, you know, if we, as we grow, you know I know that would get harder to keep that part of the culture, but man, it's the early days. If you can just capture that magic of the stress and the trenches and have responses like that from all your employees, you know you can go out and teach a pretty good course. Chris: Yeah, yeah, absolutely Well, and get to your point. I think you know one of the goals of a company should be hire really good people, give them good opportunities, autonomy, training so that they become really good so good that they're marketable anywhere else in your industry or others, but also have a culture that's so good they don't want to leave. Yeah, Right, and if you can hit on those two things, man, it's like the key to the kingdom. Aaron: It is, it is and those people are priceless and you know our goal is down the road. If there's a big exit or something like that, I mean loyalty gets rewarded right, and you don't forget those times, because those are meaningful for business owners. Chris: Very good. That's great, man. It's great. What a cool story. I mean like seven years, yeah, it has been. So let's, we'll turn it a little bit on the lighter side. What you know growing up, what was your first job? Aaron: My dad's a large animal vet and so I was shoving the proverbial you know what. So, yeah, I worked at his vet clinic quite a bit, so it was a lot of painting, a lot of fence building a lot of you know cutting hay out in the pasture. Chris: So I was a farm boy. That's funny. So my dad was a primarily large animal and there was a big pile behind the stalls and that was one of the jobs and his partner's sons and I, yeah, I could totally relate. Exactly, that's too funny. Well, you know, not necessarily the best segue from shoveling that stuff, but I'm going to ask you do you prefer Tex-Mex or barbecue? Aaron: oh, tex-mex. All right, tex-mex. Yeah, you know it's. I've lived around the world and I you know, I know it's not exactly true, but I mean, it seems like you can find barbecue or barbecue adjacent foods almost everywhere, man, tex-mex, you just cannot find it. I mean, it's just you. There's tex-mex everywhere, but it's not Tex-Mex unless it's here. Chris: I think that's a pretty true statement. Yeah, and then the last question. I'm curious to know if you could take a sabbatical for 30 days, where would you go and what would you? Aaron: do. Oh man, if I could take a sabbatical for 30 days, you know I would go back. So we spent a lot of time as a family over in Europe and in France and in small towns. So you know there's just a, it's a part of that world. You know, if you asked me where I would go you ask a lot of people where they would go in France they'd say Paris. Paris is okay. I like the small towns, I like the history, the quietness that you get in a lot of those places. You know rivers and streams running through it. So I just found that part of the world to be especially peaceful. And if it's a sabbatical, you know that's where I prefer to be. Good food yeah, can't beat it. Good wine yeah, really good wine yeah, can't leave that part out. Chris: No, not at all. Well, aaron, this has been an amazing conversation, love and your story that you and Marshall and others have created. So thanks again for taking the time. Yeah, appreciate it, chris. Thank you, Special Guest: Aaron Knape.

When you are in that terribly complicated time of making medical decisions around advanced cancer, what framework can you turn to? Oncologists are called upon to treat and offer options; patients hope to gain time if not be cured. What are the choices and the impact of those choices for advanced solid tumor cancers? What if I told you that two doctors have gathered the data to find out whether certain treatments extend life or not. Would you listen to that conversation to find out more? I would!

The world needs physician voices. Enjoy a fun conversation with Hilary Blair, founder of Articulate Real & Clear, about how mindfulness, intention, and most of all presence can help anyone, especially doctors, give a great talk. The way we are trained to think as physicians makes public speaking more of a challenge than it should be for most physicians.  We are trained to: worry what others will think of us fear judgment, rejection, and shame talk fast and "not waste time" always share as much information as possible  be sure others think we know "enough" not take risks  blame ourselves if we make a mistake (or even if others think something not flattering about us) xatastrophize what might happen if we make a mistake or embarrass ourselves    Most physicians find it very uncomfortable to be seen as an expert or a star. We were taught this could be perceived as gloating. It could also lead to complacency and maybe a mistake. We tend to prefer to “serve” others under the radar. We are trained that there is “a right way” and that, if you haven't been trained, "you don't know how." We tend to default to thinking that we are imposters. We fear that someone may discover we don't know everything about everything.  What can we do to improve our public speaking? Choose connection over perfection  Do more of what's working and less of what's not Work with a mindset/life coach (AKA Jessie) to understand our patterns, how our brain works, and how we can optimize our performance in the exam room, on a stage, and at home Practice owning our authenticity, wisdom, and expertise every day Practice mindfulness and learn how to drop into our body  Connect with our intentions, as a speaker and otherwise Work with a speaking coach to clarify our message, tone, and energy   Hilary Blair is the CEO of ARTiculate: Real and Clear.  She is an energized speaker, trainer, facilitator who capitalizes on her professional voice over and stage training techniques - where she used to put the drama in, she now takes the drama out of team and leadership communication. She facilitates and leads programs internationally for corporate teams and leadership to elevate presence, communication, and authentic connection. Clients include AWS, Starbucks, ACLU and MD Anderson. Hilary is a TedX speaker, a cofounder of ARTiculate: Real&Clear and holds an MFA in acting from the National Theatre Conservatory and a BA from Yale University. How to work with ARTiculate Real and Clear- https://articulaterc.com Move beyond consuming this amazing podcast. True change happens when you work with us - virtually and/or in-person. Coach with Jessie - 1:1, in a small group, or at a retreat. www.jessiemahoneymd.com Work with both of us in person at The Mindful Healers Annual Retreat www.jessiemahoneymd.com/retreats Hire one or both of us to speak or lead a workshop on any topic covered in the Mindful Healers Podcast. We also create team retreats, teach yoga, and offer experiential mindfulness for teams, groups, grand rounds, institutions, and conferences. www.jessiemahoneymd.com/mindful-healers-podcast www.awakenbreath.org  www.jessiemahoneymd.com/speaking *Nothing shared in the Mindful Healers Podcast is medical advice.   #physicianwellness #mindfulnesscoach #pauseandpresence #physiciancoach  

How do you navigate breast cancer when you know the health care system is stacked against you? And, how, as a health care provider, can you best support marginalized people going through the experience of breast cancer? Let's find out. In this episode, Jasmine Samuel, a TNBC survivor and Black nurse shares how her experience of suboptimal care in Jackson, Miss., encouraged her to actively seek out a better care experience from MD Anderson in Houston, Texas. We'll also hear from Komen Scholar Dr. Mariana Chavez MacGregor, a breast medical oncologist and professor at the Breast Medical Oncology Department of MD Anderson Cancer Center who will discuss how she provides compassionate care and focuses research on improving outcomes for underserved patients.