How is head and neck cancer treatment evolving over time? Watch as expert Dr. Samantha Tam from Henry Ford Health System explains current areas of research focus in head and neck cancer – and how researchers are working toward the best care for patients.
Samantha Tam, MD, FRCSC, MPH:
So, treatment of head and neck cancer is constantly evolving with the introduction of immuno-therapeutic agents, understanding the role of that in the treatment of head and neck cancer is currently undergoing a lot of research. And there’s a lot of interest in curiosity about how we can utilize that in conjunction with the more traditional treatments of head and neck cancer. Another major focus in head and neck cancer now is to ensure that we’re not overtreating our patients, especially those with HPV-positive disease, and so understanding the balance between treatment care of the disease as well as maximizing function and quality of life after treatment of the disease has become a major focus in head and neck cancer and is certainly at the forefront of our minds.
For head and neck cancer patients, do telephone-only visits really qualify as a telemedicine visit? Watch as expert Dr. Samantha Tam from Henry Ford Health System explains care concerns that can be covered in telephone versus video visits – and patients who can benefit from the use of virtual visits.
Samantha Tam, MD, FRCSC, MPH:
So from a… Telephone-only visits have a lot of drawbacks to them, I think even virtually assessing a patient with regards to how they’re doing generally, a general physical examination is very important. On top of that, we have a lot of sensitive conversations in patients that have head and neck cancer, so it’s important to also read things like non-verbal body language, so definitely the video component is extremely useful for providers that are caring for patients with head and neck cancer. However, in patients that might not have access to video visits, might not have the technology, I think that the number one priority in our minds is that this patient gets the best care that they are able to get, and whether that this means a telephone-only type of a visit is possible for these patients, we adjust our…I guess we adjust our requirements, we adjust our ability to deliver care based on that, so that might mean touching base with the patient on the phone at first in order to understand exactly what they’re going through, talk them through the next steps so that they know what to accept in order to make their care more streamlined later on. I don’t think that telephone visits will completely replace either virtual visits or in-person visits, but I think that, again, they are a tool, and they’re a tool that especially patients that might be more disadvantaged, such as not having access to good Internet might not have access to the technology required for a virtual visit, those patients need to be considered when we consider utilizing telephone-only care.
Will head and neck cancer care continue with telemedicine in the future? Watch as expert Dr. Samantha Tam from Henry Ford Health System shares her perspective on her expectations for the use of telemedicine versus in-person visits with head and neck cancer patients.
Samantha Tam, MD, FRCSC, MPH:
So while COVID-19 has forced us into utilizing telemedicine in context that we might not nearly have used them in the past, I think that telemedicine is here to stay, though perhaps not as wide spreading universal as it has been at the beginning of the pandemic. Telemedicine to me, seems to be a very good adjunct to our in-person visits, I think seeing patients and evaluating them in-person is essential in head and neck cancer throughout the treatment course. That being said, I think that telemedicine really adds a value into patient’s care, there are several ways that we have used this at Henry Ford in order to enhance access to our services, one is with patient intake, when we have some information, we can certainly start to…we can meet with you, get a good clinical history and understand exactly what is going on, and therefore expedite investigations that are required, and then condense our visits to just one in-person visit versus multiple in-person visits. Another way that I have used this is checking in with patients while they’re in the middle of treatment, sometimes patients are getting daily radiation, not close to my office, but I like to check on them to make sure from a symptom standpoint that they’re tolerating their treatment well.
And certainly coming down for a visit would be impossible, so checking in with them virtually has been a good way to monitor treatment side effects and to ensure everything is going smoothly from that standpoint. With surveillance, there have been also options that way to check in with patients that are more on the survivorship end of things to see how things are going that way though, I often do like to see patients in follow up in-person just so that we can also complete an endoscopic examination as clinically indicated.
For head and neck cancer patients, which treatment side effects are acceptable to be monitored via telemedicine? Watch as expert Dr. Samantha Tam from Henry Ford Health System explains vital aspects for monitoring treatment side effects, key symptoms for patients to report, and some patient monitoring methods that are helpful in care.
Samantha Tam, MD, FRCSC, MPH:
One of the most important aspects in terms of treatment side effects is understanding what the patient feels with regards to their symptoms and reporting this to the physician. Something that we’re using at Henry Ford currently is remote patient-reported outcomes measurement, which looks at several domains of symptomology that we are monitoring throughout your treatment. These questionnaires can be completed online remotely at home, and don’t necessarily need an in-patient visit. This is a platform that can be utilized to communicate with providers in order to understand what the treatment side effects might be, and also a standardized way to discuss with your physician exactly what kind of side effects you might have from treatment.
So I think it’s important to be a self-advocate for your care, and so certainly as a provider, I’m happy to hear any kind of concerns that you have about side effects from treatment, pain, bleeding. I think one of the big ones is whether or not you’re doing well with swallowing and how your weight has been. Energy level is another major indicator about how much you’re able to take in and how well you’re tolerating the treatment. All these types of components are important things for us to know throughout your treatment course, and I think speaking up about any kind of concerning symptoms you have is important for your provider to know so that we understand exactly what’s going on.
How can head and neck cancer patients prepare for telemedicine visits? Watch as expert Dr. Samantha Tam from Henry Ford Health System shares her tips for telemedicine best practices and tests that can be helpful used in conjunction with virtual care.
Samantha Tam, MD, FRCSC, MPH:
So in head and neck cancer, a lot of the virtual visits are mainly based on obtaining a clinical history and having a discussion with your provider verbally as opposed to a lot of physical examination, this is unfortunately the limit of virtual care, and definitely, especially in head and neck cancer, a lot of our examination is through into your ears, into your nose, into your mouth with endoscopic examinations weaved into it, and definitely like CT scans are useful as a modality, as a modality of investigation to have ready prior to your visit with your head and neck cancer provider. Tips that I have for families and for patients that are facing a diagnosis of head and neck cancer before your virtual visit is to make sure that you have any kind of questions that you have written down so that you can make sure that your provider is able to go through each one of these questions to ensure that you have a good understanding of exactly what the next steps are, or what the diagnosis is and what the plan might be moving forward.
How have head and neck cancer clinical trials been impacted by telemedicine? Watch as expert Dr. Samantha Tam from Henry Ford Health System provides her perspective on scenarios when telemedicine can improve clinical trial access and how care disparities can be changed through the use of telemedicine access.
Samantha Tam, MD, FRCSC, MPH:
While I don’t have specific data on how clinical trial participation has been impacted through telemedicine, I believe that the impact would be several ways, one is that patients that might not be able to access in-person care at a certain center may be introduced to an interesting clinical trial and therefore seek care at a specific center based on that clinical trial, but also there may be patients that might not be able to access the clinical trial because they have not been able to access in-person care at those centers. My current research is not so much in the clinical trials realm, but more exploratory currently, and looking at how we can empower communities that may be at an disadvantage to access telemedicine and virtual care, especially in these times when all institutions have been moving more towards using technology in their delivery of care, so as to ensure that patients are not left behind just because of their potential disadvantages.
What are instances for head and neck cancer patients to seek in-person visits for care? Watch as expert Dr. Samantha Tam from Henry Ford Health System explains situations that warrant in-person visits to care providers and her recommended precautions to ensure optimal safety for in-person care.
Samantha Tam, MD, FRCSC, MPH:
So to protect yourself from the Delta variant of coronavirus, one of the most important steps would be for vaccination and also following national guidelines in terms of how to protect yourself generally, like good hand hygiene, mask wearing, et cetera, et cetera, in terms of trying to seek care virtually versus in-person, patients should discuss this with their provider to see exactly what they are comfortable with, some post-operative visits might be able to be moved to a virtual platform, but again, sometimes it is difficult to examine patients with…that have undergone complex head and neck cancer surgery on a virtual platform adequately. So I think that a one-on-one discussion with your provider should give you a good idea about what can be moved in-person onto a virtual platform, and that way you can ensure that you have the adequate amount of care that you need for your head and neck cancer.
Okay. Seeking in-person care, I think is especially important for patients that are having symptoms from their head and neck cancer, these patients are the ones that I would consider at highest risk for some type of abnormality on physical examination that we might not be able to catch on a virtual platform, and patients that are far out from surveillance and well into survivorship, these visits might be less necessary to be in person. So again, I think it’s important for you to discuss with your provider regarding whether or not they think that you need to be seen in person versus virtually.
Which head and neck cancer patients have experienced disparities in telemedicine access? Watch as expert Dr. Samantha Tam from Henry Ford Health System explains patient demographics with less access to care and how these disparities can be reduced.
Samantha Tam, MD, FRCSC, MPH:
So, during the pandemic, there was a large uptake of virtual care that was pretty unprecedented previously, and a lot of the times patients didn’t have any other options aside from accessing care through telemedicine because of the precautions that were taken within institutions in limiting in-person care. With this, we saw that there was a very specific demographic that we’re able to access telemedicine, and there were some patients that potentially could have been left behind. These patients are usually patients that have lower SES (socioeconomic status) indicators such as lower median household income, or perhaps lack of insurance coverage and the difficulty, especially in head and neck cancer, is that a lot of the times, these are the same patients that are at highest risk for head and neck cancers or have the highest needs in head and cancer. And certainly understanding who these patients are is extremely important, so that we ensure that we have equitable delivery of health care to these patients, and we don’t utilize these platforms that put these patients that are already at a disadvantage at more of a disadvantage.
For head and neck cancer patients, what barriers and opportunities have emerged from the addition of telemedicine? Watch as expert Dr. Samantha Tam from Henry Ford Health System shares insight about obstacles that she has seen for some patients and some helpful ways these challenges have been overcome in patient care.
Samantha Tam, MD, FRCSC, MPH:
So there are lots of challenges and opportunities for virtual care and patients with head and neck cancer. One of the challenges is the fact that a lot of head and neck cancers occur within the upper air or digestive tract and therefore it’s very difficult to examine patients or to get an idea of the extent of their cancer, or the disabilities, or difficulties patients encounter as a result of their cancer, because of where the cancer is. On top of that, a lot of patients present to us with difficulties with communication, either they have hoarseness because of glottic cancer or maybe they have airway distress and they already have a tight tube resulting in their inability to formulate well, especially over virtual platforms such as the telephone or virtually through the Internet. These are the major challenges though, they can be overcome with things such as typing answers through the chat functions, as well as writing on a tablet in order for us to read. However, there have been a lot of opportunities for patients with head and neck cancers, I think that the major opportunities are with patients that are seeking help from allied health professionals such as speech language pathologists, psychologists, dietitians, social workers, a lot of these providers that are very involved in the care of patients throughout diagnosis, treatment as well as surveillance.
These visits are sometimes not requiring any physical examination, not requiring any endoscopic examination and may be well completed through a virtual platform such as telemedicine.
How has head and neck cancer care changed from the COVID-19 pandemic? Watch as expert Dr. Samantha Tam from Henry Ford Health System shares situations for in-person vs. telemedicine visits.
Samantha Tam, MD, FRCSC, MPH:
COVID-19 has significantly changed how healthcare is delivered to patients with head and neck cancer. Traditionally head and neck cancer care has been delivered in-person visits because patients with head and neck cancers are often difficult to examine on a virtual platform, and on top of that, many patients have difficulties with communication, just given the ramifications of the disease. However, with COVID-19, we had a conscious effort to shift a lot of our care from in-person to virtual visits, and the area of telemedicine has been therefore greatly expanded in patients with head and neck cancer diagnosis. How head and neck cancer patients have been able to utilize telemedicine has been varied according to whether or not these patients are coming in for new diagnoses for follow-up care, for post-op diagnoses or for care during their treatment. And I feel that virtual care is really complementary as opposed to a substitute for patients with head and neck cancer because certainly there are innate difficulties in communication through the virtual platforms, as well as innate difficulties with examining patients adequately through the virtual platform.
That being said, there’s a lot of care, for example, with allied health professionals, or surveillance care that can be completed on a virtual platform that may use healthcare delivery to patients that may not be able to access in-person care on a regular basis
On April 27, 2020, I received an email plea for help from Debra after she had read my book. Deb’s husband, Jeff, was struggling with a very malignant form of parotid cancer called Acinic Cell Carcinoma that, despite surgery and radiation, had spread to his chest and spine. Worse yet, there were no clear treatment choices available. Over the next 11 months, Deb & I have maintained an almost constant contact via emails and telephone chats. It has been my honor & privilege to get to know Deb. I am most impressed by her innate intelligence, rock solid determination and steadfast perseverance. Jeff is alive today primarily due to Debra’s tireless efforts to find a solution.
On my request, Deb has penned this story of Jeff’s illness. I sincerely hope that it will inspire other patients and caregivers to become more empowered. Remember, Knowledge is Your Superpower. Sajjad Iqbal, M.D.
My husband, Jeff, was diagnosed with high-grade acinic cell cancer of the parotid gland in February of 2018 at the age of 65. He was a very young, healthy 65, who rarely saw a doctor and needed no regular medications. For 37 years he was a teacher and coach at a small school in Iowa. We have now been married for 47 years, have three children and three grandchildren. Jeff retired early from teaching when he was 61, but continued coaching for several more years. He also did small construction jobs with our son. We spent a lot of time traveling by car throughout the United States. It was a shock to both of us to hear that Jeff had this disease since he seemed to be so healthy.
Several years before Jeff was diagnosed, he mentioned a small lump behind his ear. During a brief physical he had, he asked his doctor about it and was told to keep an eye on it and, if it got bigger, to see a doctor. In January of 2018, he noticed it was getting bigger so he saw the doctor. He was told he needed to get a biopsy but it was probably just a blocked salivary gland. As soon as I heard that, I figured it was cancer as Jeff’s mother had been diagnosed with salivary gland cancer many years before. Hers was a slow growing adenoid cystic cancer that was treated with surgery only. He had his biopsy done at a local hospital and when they said it was cancer, we had them make him an appointment at Mayo Clinic in Rochester, Minnesota which is only a couple of hours from our home.
He had further testing done at Mayo which also showed a lesion at the top of his spine. In March of 2018, he had two separate surgeries to remove the tumors. Cancer was also found in 9 of 21 lymph nodes. He came through the surgeries with no problems. Soon after, he received six weeks of radiation on both of those spots. This was much tougher on him than the surgeries. His neck was badly burned, nausea, no appetite, etc. He made it through and slowly got back to feeling normal. At that time, we were told that chemo wouldn’t help him so he never received any. Three months later, a scan showed a nodule on his chest wall. They did a biopsy and found it to be the same type of cancer. He had a cyroablation on that spot.
Two months later, we found out that the cyroablation had not worked, the spot was bigger and there were several spots on bone. He had Foundation One testing done on his tumor and it showed very few mutations. There was only one mutation, RET, that had a possible treatment at that time. There was a clinical trial at Mayo for a targeted drug for that mutation and they were able to get him in. He started on that in February of 2019. He experienced no side effects and the chest wall tumor stayed about the same the entire time he was on the trial. Unfortunately, though, it was not stopping the bone mets. He had radiation three days in a row on a couple of them when they started causing him pain. Because it was not stopping the bone mets, he discontinued the trial. His oncologist told us that he didn’t know of any clinical trials at that time that would help him. The only thing he had to offer was chemo and possibly Keytruda but he was doubtful they would help very much. Needless to say, this left us feeling lost as to what to do next.
The Mayo oncologist had told us that, in his opinion, clinical trials were the best way to go as you could get the newest treatments and you would be closely monitored. That is what I decided to look for first. Luckily, since Jeff was first diagnosed, I had been doing research on his cancer and possible treatments. There wasn’t a lot as it is a rare cancer. I have no medical background but was determined to figure things out as much as I could and find something that might be able to help. I found three clinical trials that I thought might work for Jeff. These trials did not exist when Jeff was first diagnosed. I sent them to his Mayo oncologist who had told me that he would be willing to look over a clinical trial if I found one. He agreed that the one I was most interested in looked like a good possibility and one of the trial locations was Iowa City which is about 3 hours from us. This is a trial that focuses on the genetic makeup of the cancer instead of the type of cancer. One of the mutations that Jeff has is FANCA and this trial was the first one I found where FANCA was one of the mutations they were looking for. Also, Jeff’s mother, who also had salivary gland cancer, is a carrier of the FANCA gene. There is no known relationship between the FANCA gene and salivary gland cancer but I feel there must be a connection. It is a rare cancer and to have a mother and son have it must be extremely rare. Our children have been tested for this gene and we discovered that our son is also a carrier.
It was in February of 2020 when we went to Iowa City to try to get Jeff into the trial. We found out that they had changed the requirements for the trial and now you had to have had chemo in order to be accepted. The doctor started Jeff on the oral chemo drug, Xeloda, and told us that if anything grew, he would stop the chemo and try to get him in the trial. Jeff was also having some rib and back pain and that was treated with five days of radiation therapy. Following those treatments, he had some heartburn issues for a couple of weeks after which it slowly resolved.
At first, the chemo wasn’t too bad. Soon though, there were many nasty side effects; peeling palms and bottoms of feet, nausea, no appetite, etc. He did not feel up to doing much and spent a lot of time sitting or lying down. He was on this about five months and decided to stop due to the side effects. He was having some back pain during his chemo and was prescribed a narcotic pain reliever. It helped the pain some, but caused constipation, so he had to take more medication for that. He told the doctors he did not like taking the narcotic drug and wanted to find another alternative. They tried one drug and the first night he took it he ended up fainting and having make a trip to the hospital. Needless to say, we stopped that drug right away! They said he was having nerve pain from his spine but were not able to find the exact source. He ended up having a vertebroplasty on his spine as they thought it might help his pain.
Unfortunately, it didn’t help the pain and he also started having a weird feeling of a tight band around his abdomen. We made a trip back to the Mayo Clinic to see a pain specialist there. He thought Jeff might be helped with a nerve block on either side of his spine. He had this done and, not only did it not help, it made the band feeling we were trying to get rid of feel even tighter! This was very disheartening as we really thought it would help. Iowa City had started him on Gabapentin for his nerve pain and had been slowly increasing the dosage. He was also started on a low dose of Lexapro and, between those two drugs, he started to feel less pain in his back. The “band” feeling is still there, but not as bad as it once was. He was finally able to get into the clinical trial in August of 2020. The drug he is on now is a parp inhibitor that targets the FANCA pathway. He has been on this drug for about seven months now with almost no side effects. The targeted tumor has shrunk quite a bit and the bone mets have stayed the same. Unfortunately, on his last scans, there was a new spot on his liver. He was allowed to stay in the trial as it is working on his targeted tumor and he is scheduled soon for microwave ablation on his liver.
When one treatment stops working, I always look for a new clinical trial first.
It is hard, however, as so many of the trials are for certain types of cancer. Even though you discover (from the mutations) that a certain drug may help your cancer, you can only be in that trial if you have a certain type of cancer. I hope in the future there are many more trials based on the genetic makeup of the cancer rather than the type of cancer. The other problem is that the majority of trials are held at larger hospitals that are just too far away to go back and forth as often as needed. It would be great if there were a way to have some of the treatments done at a larger hospital in your own state. Also, if you have a rare cancer, it is much harder to find clinical trials.
I have a library background and have always relied on books and articles to find information about various topics. Now that the internet is available that has been my most important tool at this time. Also, websites like PEN, providing patient’s stories, healthy recipes and classes are very helpful. These types of sites have really helped me feel not so alone and have given me much more hope than I have ever received from any oncologist. It is also over the internet that I connected with Dr. Sajjad Iqbal after reading his book “Swimming Upstream.” He has been very generous with his time and willing to give suggestions and advice as he has a cancer similar to Jeff’s. It has been a great comfort to me to be able to e-mail him to get his opinion on something or ask a question. He has also helped me feel more hopeful than anyone else I have talked to – not only by his words but by his courageous example.
When Jeff was first diagnosed, he was still coaching track. The entire track team wanted to have a benefit for him and sold t-shirts and wristbands, and had a meal and dodge ball tournament to raise money for him. Jeff is a very popular guy in this rural school district and I know it meant a lot that his team did this for him. We have support from our family and friends and feel that we have people we can call if we need something. The pandemic has kept us from getting together with people as often as we would like but we are looking forward to that in the future.
We know that there is a good chance that Jeff’s cancer may never be cured. If that is true, I would like the next best thing – for him to live as long as possible, as well as possible with the cancer. We have had three very good years living with it and working around his medical appointments. I will do everything I can to help him have more of those years.
Jeff has handled this whole situation very well from the beginning. He is a pretty laid-back person who takes things as they come and isn’t much of a worrier. He has kind of set an example for me just by taking things as they come. I feel his job is to fight the cancer and my job is to help him fight the cancer. Our lives are pretty much the same as they were before he was diagnosed – only with a lot more doctor appointments!
Sajjad Iqbal is a physician and cancer survivor. Almost 17 years ago, Sajjad learned that he had an extremely rare and most malignant type of parotid cancer called Salivary Duct Carcinoma. He was given a 30% chance of surviving for 2 years. Because of Sajjad’s medical training and his unwavering sense of hope & determination, he was no ordinary patient. Sajjad researched his condition and proposed a treatment method for himself that stopped the progression of cancer cells. Although Sajjad is still living with, and still fighting, the cancer, he continues to defy the odds with no end in sight. To inspire other cancer patients, Sajjad Iqbal has chronicled his amazing cancer journey in the form of a book titled, “Swimming Upstream, My Struggle and Triumph over Cancer and Medical Establishment.”
What steps could help you and your doctor decide on the best treatment path for your specific cancer? This animated video explains how identification of unique features of a specific cancer through biomarker testing could impact prognosis, treatment decisions and enable patients to get the best, most personalized cancer care.
If you are viewing this from outside of the US, please be aware that availability of personalized care and therapy may differ in each country. Please consult with your local healthcare provider for more information.
Hi! I’m Dr. Jones and I’m an oncologist and researcher. I specialize in the care and treatment of patients with cancer.
Today we’re going to talk about the steps to accessing personalized care and the best therapy for YOUR specific cancer. And that begins with something called biomarker testing.
Before we start, I want to remind you that this video is intended to help educate cancer patients and their loved ones and shouldn’t be a replacement for advice from your doctor.
Let’s start with the basics–just like no two fingerprints are exactly alike, no two patients’ cancers are exactly the same. For instance, let’s meet Louis and another patient of mine, Ben. They both have the same type of cancer and were diagnosed around the same time–but when looked at up close, their cancers look very different. And, therefore, should be treated differently.
We can look more closely at the cancer type using biomarker testing, which checks for specific gene mutations, proteins, chromosomal abnormalities and/or other molecular changes that are unique to an individual’s disease.
Sometimes called molecular testing or genomic testing, biomarker testing can be administered in a number of ways, such as via a blood test or biopsy. The way testing is administered will depend on YOUR specific situation.
The results could help your healthcare team understand how your cancer may behave and to help plan treatment. And, it may indicate whether targeted therapy might be right for you. When deciding whether biomarker testing is necessary, your doctor will also take into consideration the stage of your cancer at diagnosis.
Right! My biomarker testing results showed that I had a specific gene mutation and that my cancer may respond well to targeted therapy.
Dr. Jones, Can you explain how targeted therapy is different than chemo?
Great question! Over the past several years, research has advanced quickly in developing targeted therapies, which has led to more effective options and better outcomes for patients.
Chemotherapy is still an important tool for cancer treatment, and it works by affecting a cancer cell’s ability to divide and grow. And, since cancer cells typically grow faster than normal cells, chemotherapy is more likely to kill cancer cells.
Targeted therapy, on the other hand, works by blocking specific mutations and preventing cancer cells from growing and dividing.
These newer therapies are currently being used to treat many blood cancers as well as solid tumor cancers. As you consider treatments, it’s important to have all of the information about your diagnosis, including biomarker testing results, so that you can discuss your treatment options and goals WITH your healthcare team.
Exactly–Dr. Jones made me feel that I had a voice in my treatment decision. We discussed things like potential side effects, what the course of treatment looks like and how it may affect my lifestyle.
When meeting with your healthcare team, insist that all of your questions are answered. Remember, this is YOUR life and it’s important that you feel comfortable and included when making care decisions.
And, if you don’t feel your voice is being heard, it may be time to consider a second—or third—opinion from a doctor who specializes in the type of cancer you have.
So how can you use this information to access personalized treatment?
First, remember, no two cancers are the same. What might be right for someone else’s cancer may not work for you.
Next! Be sure to ask if biomarker testing is appropriate for your diagnosis. Then, discuss all test results with your provider before making a treatment decision. And ask whether testing will need to be repeated over time to identify additional biomarkers.
Your treatment choice should be a shared decision with your healthcare team. Discuss what your options and treatment goals are with your doctor.
And, last, but not least, it’s important to inquire about whether a targeted therapy, or a clinical trial, might be appropriate for you. Clinical trials may provide access to promising new treatments.
All great points, Dr. Jones! We hope you can put this information to work for you. Visit powerfulpatients.org to learn more tips for advocating for yourself.
Thanks for joining us today.
This program is supported by Blueprint Medicines, and through generous donations from people like you.