An MPN Care Partner Shares Why He’s Optimistic About the Future

An MPN Care Partner Shares Why He’s Optimistic About the Future from Patient Empowerment Network on Vimeo.

Care partner Jeff Bushnell, husband of myelofibrosis (MF) patient advocate Summer Golden, explains why he’s hopeful about their future together. Jeff shares key resources that have helped him stay educated and maintain optimism.

Summer Golden and Jeff Bushnell have been married for over 20 years. When Summer was diagnosed with myelofibrosis (MF), Jeff took on the role of care partner and advocate. Summer uses her years of theatre training and comedy to cope with her condition and help others, while maintaining positivity about the future.

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Transcript:

Jeff:

It’s important to educate yourself because the more you know the less fear can overcome you. And this particular disease – the research is happening so fast, and things are changing. In my estimation, they’ll find – right now, the only cure is a stem cell transplant. It’s normally not done for older people. That in itself is innately risky. I’m convinced, probably within the next five to seven years, there will be a cure for this disease that’s not a stem cell transplant.

The research is moving that quickly on it. And if you don’t follow the disease and the people that are working on it, the specialists, you’re gonna have a much greater chance of feeling powerless and getting overwhelmed by it. As Summer believes, attitude can have a huge, huge impact on how the course of your disease runs. And a doctor would tell you the same thing.

For me, it started with Patient Power. Patientpower.info, I believe is, what it is. They have a whole section for myeloproliferative neoplasms and myelofibrosis, and they’re short videos. And you get a chance to listen to the best doctors that are the head people in this, Dr. Mesa, Dr. V [Verstovsek], and Dr. Jamieson – all the people that are really the movers and shakers. They speak. And you also get a chance to hear other patient’s stories and how they’re dealing with it. And that will give you a much better idea of what you’re facing. And you can really understand things from there. And you can get your knowledge.

Fear comes from lack of knowledge. In my job as a pilot, I flew for 50 years. I very, very rarely was afraid because my knowledge was so great and was reinforced every year by continual training that I felt prepared to handle anything that might come across to me. Knowledge is really important. It will allay your fears dramatically.

When I started online and heard about people that had been journeying with this for 10 or 15 years, initially, I had thought – well, this is a year or two, and it’ll be the end. And then I realized, plenty of people have lived with this for a long, long time. And they had a journey, and they’re doing it successfully. And that gave me confidence.

The more people you can talk to about it, the more you can put your journey in perspective. And it’s really hard to put in perspective for this particular disease because it affects everybody vastly differently. Some cancers – the progression is very, very linear. Everybody kind of goes through the same thing. This one – it depends on the mutations you have in your blood and all kinds of things like that, and some people get really bad symptoms quickly.

Others, they don’t. But the more you know about how those things affect you, the more you know and can understand about what to expect. And the more people you talk to who have it, you can find out about their journeys. It helps put yours in perspective.

I’m optimistic because I really keep up to date on what’s going on. And I see the doctors that are in the forefront of this and the research that they’re putting in and the care they have for working on this disease and the knowledge they have, and I just am quite optimistic. And as I say, I’m following the medical developments extremely closely.

I went to the ASH Conference last year. And I’ve gone to another conference that our doctor spoke at. And I’m just kinda blown away by – I’m fascinated by the science.

My advice would be find out as much as you can about it and support each other in a way that works in your own marriage.

Summer and I approach life a little bit differently. And yet, one of the reasons we do so well together is we kinda have both ends of the spectrum covered. And I sensed that when I met her 20 years ago. And we brought something to the table that each of us needed. And if you can find that in your relationship with your significant other that has the disease, what you can bring to it, what they can bring to it, you can be a tremendous support for each other.

A Care Partner’s Journey: How Life Goes on After an MPN Diagnosis

A Care Partner’s Journey: How Life Goes on After an MPN Diagnosis from Patient Empowerment Network on Vimeo.

Care partner Jeff Bushnell shares how he and his wife, patient advocate Summer Golden, have dealt with her myelofibrosis (MF) diagnosis. Jeff explains how online support and finding an MPN specialist were essential steps in helping them continue to live life to the fullest.

Summer Golden and Jeff Bushnell have been married for over 20 years. When Summer was diagnosed with myelofibrosis (MF), Jeff took on the role of care partner and advocate. Summer uses her years of theatre training and comedy to cope with her condition and help others, while maintaining positivity about the future.

 

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Transcript:

Jeff:

The worst part was initially. We didn’t get a myelofibrosis diagnosis.

It took about a month because in order to definitively diagnose it they have to take a bone marrow sample and send it to a pathologist and so on and so forth. So, all that time, I’m worrying about the possibilities. It could be leukemia or this, that, or the other thing. My way of handling and dealing with scariness – I’m a retired pilot – is to find out things, knowledge.

I spent a huge amount of time on the internet. The LLS Society has papers about it, and I read those.

And the more I got into it – once we found out it was myelofibrosis, I’ve read almost all of the papers that the doctors write for each other to find about this. That doesn’t interest Summer in the slightest. It interests me greatly. So, when we have an appointment with the doctor – when I’m talking to the doctor, it’s like two doctors talking to each other.

When Summer’s talking to her, they talk on a different plane. It’s much more about mental approach to things and that kind of thing.

And for me, when I think back to the beginning of when we had this and where we are now two years later, we’re living the life that we lived before she was diagnosed to be real honest with you.

We do everything that we did before she was diagnosed the same way we did it before, and it was a trip that probably everybody who gets diagnosed or deals with a person that has the disease takes. When it first happened, it hit us like bricks coming out of the sky hitting us on the face. Literally, when we first went to the hospital and she got the word that there was a problem – as I say, we lived in two separate houses – I literally was afraid to call her phone figuring she might be not there. I was that scared. And then, after we met our doctor, which was extremely fortuitous – when we went to the emergency room, the person that was there, she said these look like leukemia things.

So, she called the oncologist. The oncologist on call is our current doctor, Dr. Tiffany Tanaka, and she’s a specialist in this disease. It was like it was meant to be. And Dr. Tanaka asked the guy to do some other tests and then said, “Send her home, but tell her I need to see her this week.” So, we’re thinking all these horrible things. And its New Year’s weekend, so the clinic is closed for about five days, you know? We’re worrying and worrying and worrying.

We finally saw Dr. Tanaka, and it was like a breath of fresh air. This wonderful doctor has the ability to just communicate with the patients. I’m interested in the disease, so she communicated on my level. Summer is not interested in all the medical jargon, so she was able to explain to Summer what was going on and just very, very reassuring, very reassuring.

And then, I went and started getting information. That’s my way of coping with things. The first place I went was – I went to Patient Power and found a lot of information there.

And then I found the online myelofibrosis support group at Facebook. And that was very, very useful. When I started reading about the fact that some people had this for many, many years – then I said this is not – nothing’s gonna happen in the next year or two. We can go back to living. And once we learned more about it and spent more time with our doctor and Summer was able to live her life once she got taking the medicine – she takes Jakafi.

That controlled the basic symptoms, and we haven’t looked back. We just started living our life the way we had been living it before.

Living with a Myeloproliferative Neoplasm

This video was originally published by Cancer Support Community on May 26, 2015, here.

 

MPN Patient Cafe® October 2017 – Tips for Managing Life After Diagnosis

MPN Patient Cafe® – Taking Back Control – Tips for Managing Life After Diagnosis from Patient Empowerment Network on Vimeo.

A panel of MPN patients and care partners discuss taking back control and share their tips for managing their new normal after diagnosis.

Living Well with MPNs – What YOU Can Do to Advance MPN Research

What YOU Can Do to Advance MPN Research

Living Well With MPNs – What YOU Can Do to Advance MPN Research from Patient Empowerment Network on Vimeo.

An audience of MPN patients and their caregivers joined us online or on the phone as experts discussed what patients can do to advance research and to raise awareness for MPNs.


Transcript:

Beth:

It is Blood Cancer Awareness Month so our webinar is what YOU can do to advance MPN research. I’m Beth Probert. I am a polycythemia vera patient and advocate.

I was diagnosed with PV in April, 2016 and I had about 12 months of treatment which included a few phlebotomies and interferon, Pegasys. I reacted very well to Pegasys and I am now in remission. I get my care at the University of Southern California Norris Cancer Research Center in Los Angeles. I’m coming to you live from Oxnard, California, which is just north of Los Angeles on the central coast.

I would like to start off by thanking our Patient Empowerment Network for their support, and the MPN Research Foundation for their continued partnership.

I’d like to welcome our guests today. We’ll start off with Dr. Verstovsek, who is a renowned MPN expert from The University of Texas MD Anderson Cancer Center. Thank you for joining us today, Doctor.

Dr. Verstovsek:

It’s my pleasure. Thank you very much for having me on the program.

Beth:

And I’d also like to introduce you to Lindsey Whyte, from the MPN Research Foundation. Lindsey, thank you for taking the time to join us today.

Lindsey:

Thank you so much for having me. I look forward to enjoying this esteemed panel.

Beth:

Thank you. We have two patient panelists today joining us. Both have been in clinical trials and both run support groups in their area. Our first patient panelist is Nick, and he’s coming to us from central Florida. Thanks for joining us, Nick.

Nick:

Thank you very much, Beth. Appreciate it, glad to be here.

Beth:

Great. And I’d love to introduce Andrea, our other patient panelist. And she’s coming to us today from Dallas, Texas. Thanks for joining us, Andrea.

Andrea:

Hi everybody, it’s great to be here. Thank you.

Beth:

Great. I’d like to start off our program today just getting to know a little bit more about Nick and Andrea. Nick, I’m going to start off with you. You were diagnosed with myelofibrosis in February, 2016. Let’s talk about when you were first diagnosed. What was your first move after diagnosis?

Nick:

Definitely I was quite shocked. I was asymptomatic, and the doctor who presented me with the diagnosis really didn’t give me a whole lot of information; basically a Google printout that said I had one to three years to live. So, I traveled throughout the country, hooked up fortunately with Patient Power and MPN advocacy; went to a seminar in Stanford, outside of San Francisco with a wonderful group of doctors there to really learn about the disease.

Ultimately went to May Clinic, Dr. Tefari; Hutchinson Clinic, Dr. Mesa in Scottsdale, Arizona; and finally spent time with Dr. Pemmaraju who works with Dr. V. at MD Anderson. I felt it was important to try to learn as much as we can about the disease to try to help other people behind us, so I signed up for a trial with azacitidine and Jakafi at the MD Anderson hospital, which was phenomenal. They did a wonderful job but unfortunately my blasts had spiked up and I had to go to transplant, which I did a transplant on January 15 of this year.

Beth:

Wow, you have really been through quite a lot in such a short period of time. We’re definitely going to come back to you and talk about some of those details you gave us more specifically. Thank you.

Nick:

You’re welcome.

Beth:

Andrea, I’d like to go to you, now. You were initially diagnosed with essential thrombocythemia about 19 years ago, and then you were later diagnosed with myelofibrosis about nine years ago. So, you’ve certainly had quite the journey. I’d like to hear a little bit about how you reacted when you were first diagnosed.

Andrea:

Sure. My primary care doctor was really great in seeing that my platelets were rising. And while they weren’t that high, she still sent me to a hematologist just in case; a local person here. He did know about it but wasn’t too versed in the MPN world, and we worked together and I was on anagrelide and a couple of drugs and I was doing great, no problems. My platelets were good; everything was great for ten years. And then, things started to change. I started getting tired. And the first thing he said to me was, I think we ought to send you to MD Anderson.

When I had essential thrombocytosis, I felt fine. Emotionally I was fine because I had no symptoms. But when it started to convert, when things started to change and my lifestyle changed and I got much more tired and of course anemic, that was emotionally difficult. But then I went to see Dr. Kantarjian, and soon Dr. Verstovsek, who started me on different trials, I said I am not going to sit here and die. Because I got the same thing; five to seven years, not from any of the doctors at MD Anderson, let me clarify. But I knew that it was at that point kind of a death sentence, not to be dramatic about it.

But I was not going to sit back and let that happen. So I said, what can we do? And was told let’s start you on a trial. I’ve been on five. Three of them didn’t work. One emotionally almost killed me; it was not fun at all.

But the last two, I guess I could say I was in remission. I never heard the word from Dr. V, but I felt great. My life was going along fine. The last maybe six or eight months, the drug seems to not be working as well and we’re looking for something else, possibly stem cell transplant.

Beth:

You’ve had quite a journey over about 19 years, so I’m guessing you’re really a guru to a lot of us; myself, being newly diagnosed compared to you. And I know that both you and Nick run support groups. And if I can ask you, since we’re talking right now, can you tell me a little bit about your support group and then Nick, I’ll go to you in just a few minutes. Your support group is in the Dallas area. Can you give me a little feedback about it?

Andrea:

Sure. It was actually started by someone, Karen Stern, a good while ago; I don’t remember exactly when. Unfortunately, Karen got very sick very suddenly and is no longer with us.

She had asked when she was ill if I could take it over for her. I said absolutely, I’d be happy to do that. So, we meet quarterly. We have anywhere from 15 to maybe 30 people that come. We talk about what’s new with us, what’s new with our symptoms, what reading we’ve done, how we have learned, what we’ve seen in all the different conferences, and we share a lot of information. We eat, we have a glass of wine, and it’s great fun.

It’s wonderful to be hooked up because as much as I think I try to keep up with the diseases, I learn something from people at our support group. What’s hard is when people don’t come anymore for reasons that they’re sick or other reasons, and that’s tough on the group. But it’s all part of the process, I believe.

We have a lot of communication; we talk to each other. We use Facebook and we learn.

Beth:

Wow, and it sounds like you guys have a really personal group there and happy; that in-person connection sounds wonderful. Thank you. Nick, tell us a little bit about your support group in central Florida.

Nick:

It’s definitely a little looser organization. We have probably an email list of about 15 people. We keep adding just about one person every other month or so. Unfortunately for me, we got the group together and I started just doing the emails, sharing information with people, guiding them to Patient Power, guiding them to MPN. A lot of them are trying to find doctors in smaller towns in Florida where they don’t have access to people like Dr. V, and so trying to steer them to some of the better doctors in the area.

Unfortunately then I was going through a transplant so I was kind of out of pocket. So we’ve not had a chance to physically meet. We are kind of spread out; we have people in Jacksonville, Orlando, Tampa, Miami, and Naples.

So just with my regrouping here after the transplant, we’re hoping to probably in the next month or two have our first face-to-face meeting and get some folks together, probably in Orlando, and try to get the group together. But so far, it’s just been a matter of emails; folks emailing each other back and forth. We do have a lot of it seems like mostly PV patients, and they will share different techniques and just like Andre was sharing, some of the things she’s been through. I definitely feel that being around other people who are in the same boat is so much more powerful because it’s hard sometimes to talk to your family members or friends or people at work because they just don’t get it.

They don’t understand what you’re going through and how scary it is. They can’t really give advice. So we’ve found that the support group has really been – it helps me as much as being a part of it is feeling better about what’s going on. It is kind of sad, too, as Andrea said as you see some of the folks take a turn, and you’ve got to kind of rally everybody together because it is – unfortunately, this group, it’s folks who are sick and they’re all going to have their ups and downs and we have to kind of be there for each other. So, it is one of the tougher parts of being a part of a support group as well; I agree with Andrea.

Beth:

I can definitely imagine. Just hearing from both of you and my own experience being in a support group, whether it’s in person or whether it’s online or through email, they’re just all equally effective and really sometimes the best medicine for us; a certain part of our care. I’d like to shift gears a little bit, and Lindsey I’d like to talk to you a little bit with your expertise in the field. Patients are newly diagnosed and you know, how do you convey to them the importance of educating themselves and their family and their friends? What would your message be?

Lindsey:

The MPN Research Foundation has extensive information on our website, and also when somebody registers through our online system.

And I’m not talking about the registry; just contacts us initially, we send out packets with information and we will customize those packets according to a specific patient’s need. We also do or best to hook people up with local support groups or many times people come to us looking for a doctor or a specialist, and we’ll point them in the direction of online resources or others who may be able to help them locally. We have lots of resources available to patients through our organization, and also on our website and to the extent that we can help with a specific question, then we usually try and point someone in the direction of someone else who can.

Beth:

I have to say that that’s exactly what I did. I found your website when I was newly diagnosed and I registered. I got my packet. I was so excited, it had a lot of great information for me. I also got some wrist bands, and I just felt connected.

It was one of the first organizations I found and it just really gave me a sense of really being connected. So, Dr. Verstovsek, I would like to talk to you a little bit about how do you advise your new patients about identifying trustworthy info as far as… we could all go on the internet and go willy-nilly. I was convinced I was dying after two minutes on the internet. But you must get a lot of that. You must get patients asking you what do I do, how do I get information; how do you guide them?

Dr. Verstovsek:

Just towards my endorsement of what we have discussed so far in terms of education and the patients’ engagement, I have seen some of you in my own clinic and you know very well that to every new patient, because this is a chronic disease or diseases, the patients have to be engaged.

And I always endorse them to become a partner in what we are trying to do together to control the disease and eliminate the problems, and make people enjoy life fully for as long as possible with a good control in signs and symptoms. And therefore, engagement and partnership with your doctor and self education through support groups, through symposia, through pamphlets through web is increasingly important. Because the decision-maker is the patient, after all. The doctors are here to support.

And if they can partner together throughout their lives and become good friends, and I always seem to joke about it; we become good friends for the rest of the time. We actually do, and we engage together and we try to educate each other. I learn from the patients, patients learn from me and we go through life together. And so an educated patient is the one who is the best patient because we can participate together. And the sources are increasingly available to all of us.

What we are doing her today, Patient Power on the web, MPN Research Foundation through the web, through symposia, through pamphletsthrough educational material, participating in patient symposia through educational foundations; those are also available apart from MPN Foundation. And then going to the academic centers and their websites; MD Anderson, Mayo Clinic, University of New York City. There are a number of very well established academic centers that have very nice academically-driven websites for education of the patients.

It’s not necessarily to engage at the professional level where the doctors would go and educate themselves about these rare conditions, but also the patient side of the academic sites are very well informative for the patients. This is where you get up-to-date information from very well established professionals that are engaging in education of the patients.

Plus, what you have described, Nick and Andrea, engagement at the personal patient level; support groups aerospace increasingly important for the understanding of the complexities that we are facing and understanding the diseases, and understanding the therapies and the different outcomes. Look at yourselves in this panel. We have a patient, Beth, who is an example of an extraordinarily response to a therapy in complete remission.

Nick had a progressive disease, ended up having a transplant; and Andrea has lived so many years with the condition and went through the different therapies with different outcomes and is living now way more than what her first doctor said about myelofibrosis; nine years and going very well. So, people are different. Things are improving markedly and we need to work together, and education is the primary source of that effort.

Beth:

That is fabulous. I could really see how your really personal approach to caring and educating your patients really allays their fears. I wore those shoes where I was scared, and I really admire the way that you help your patients understand what is out there for them and to see the positive approach. Dr. Verstovsek, why do you feel an MPN specialist is so important when we have patients like Nick and Andrea and myself and others out there, as opposed to just kind of avoiding the specialists? What are the things that we should be really aware of and why we should go to an MPN specialist?

Dr. Verstovsek:

MPN diseases are rare diseases. And in many circles in academia, particularly essential thrombocythemia, polycythemia vera, ET, MPV are considered benign. Yet, we know that patients can change. Andrea has changed. There might be complications that can affect not just the quality of life, but the life duration as well.

Myelofibrosis is certainly much more aggressive and progressive, and can shorten life a lot but is the rarest of the free. So, myelofibrosis being so rare, people in a community setting, in smaller academic centers don’t have much experience. ET and PV, so-called benign conditions but not to me so benign, there is a need for education not just at the patient level but also at the level of physicians. There is much effort to educate professionals about the new developments in diagnosis, in therapy, and in prognosis of these conditions.

And therefore, a second opinion is always good to get. Wherever you are, even if you come to me as a first doctor, I encourage people, patients who come to me as a first doctor to seek a second opinion if it’s necessary to fulfill that educational potential that professionals can give so the patient is fully aware of what’s happening, and to live with that condition for the duration of time that there is.

The professional impact on the patient’s life is enormous because these are conditions that people live with. And therefore, proper indication and seeking a second opinion, and perhaps visiting an MPN specialist is highly encouraged

Beth:

Doctor, how do you coordinate care from afar? If it’s just not geographically… someone doesn’t have an MPN specialist near them, can you tell us a little bit about how you would coordinate that?

Dr. Verstovsek:

This is an excellent question because the specialists are around the United States and as you aid, not everybody can be local or come very often. And therefore, communication with the local doctor and education through the email or the phone is vital. We try to form a team. Patients at my center know that we are not here just to provide one-time opinion; it is continuous engagement with the local doctor.

And the patients are always encouraged to come back at the frequency that can be absorbed by their social and financial status; every six months, every 12 months if possible with more benign conditions. Or, with more aggressive conditions more often; engage in what they do, developing new medications or advising on the proper use of standard therapies. Because it is not easy even for a patient in a community setting to apply standard medications properly because of the rarity of these conditions, particularly myelofibrosis.

So, a team effort with the specialist, with the local doctor, and the third most important is the patient themselves; fully engaged in these three triangular here will provide the most benefit for the patient’s outcome overall. And that can be done as necessary. But one thing is that sometimes I should say expectations from the MPN specialist perhaps are overshadowing what actually the expert may do.

For example, myself, I am not able to monitor patients from a distance; it’s not advisable. Therefore, the local doctor must be part of the team with the interaction through the ways that I described for the best outcome of the patients. But not one doctor that can be supervising patients wherever they are.

Beth:

And that’s wonderful to know that this option is there for them. Because we do hear from patients who are in more remote areas and feel that perhaps are not getting the care for someone that’s really more renowned in their field. So it’s so wonderful to hear about those types of patient’s and how it can really benefit the patients. Thank you.

Lindsey, I’d like to ask you a few questions about the goal of raising awareness. Why is raising awareness essential to move forward, to really move research forward?

Lindsey:

That’s a great question. You know, as most people on the phone are probably already aware, the MPN Research Foundation is very involved in funding research and trying to help direct research for MPNs. One of the things that we really need to try and understand is the course of the disease and how we can help to affect the quickest results for the patients to help them to feel better. I don’t know if that answers your question, but that’s one of the things that we focus the most on, and that’s where our projects are directed.

Beth:

That’s great information. You know, I think people tend to forget that if we are such a rare group of diseases, the MPNs, and if we’re not raising awareness, we’re missing out. And we’re missing out in  moving that research forward.

Nick and Andrea, Andrea I’ll start with you; could you just give me some ideas, maybe? Has your support group or you, yourself personally, thought of different ways to get involved to raise awareness?

Andrea:

Well, one of the things we’re trying to do is invite speakers to the meeting. And my hematologist came once, and it was on a Sunday; I thought that was a very noble thing to do. People got great information. No holds barred, he answered questions and it was great. And hopefully we’re going to have someone from Cancer Care so that questions can arise, and then people can go and ask about them and check. How to raise awareness, I think it’s talking to people, I think it’s participating in maybe the LISTSERVs. It’s participating in things like this where they tune in and hear things and ask their questions.

I think it’s part of it on Facebook, encouraging people to go to meetings and to get more educated.

Beth:

Those are all great ideas. Nick, do you have a few ways or things that you’ve done either individually or through your support group that you try to raise awareness?

Nick:

Yes. I was kind of fortunate in that several years ago I was president of a company headquartered here in Tampa called Beef ‘O’ Brady’sWe had 270 sports pubs, kind of like a Buffalo Wild Wings. And then more recently I have a company called Little Greek, and we have 33 restaurants. We have five or six in Dallas and 17 here in Tampa. So fortunately the local media kind of got behind me and they did several articles about my disease, talking about myelofibrosis, trying to help us find – we signed up 700 Be the Match folks. Because I was trying to talk about the importance of getting people in this Be the Match database.

And then my wife did a blog going through the transplant process; she had over 10,000 hits and we actually set it up where it’s in book form where you can order it on Amazon and we’ve given it out to folks as well. So, we’ve definitely been pretty proactive here in the Tampa market with the Tampa Bay Times and Tampa Bay Business Journal and the Gulf Course Business Journal. They’ve been very nice about covering my experience and some of the ups and downs, and going into transplant when you don’t know if you’re going to make it, and how do you set up your business.

So we’ve been pretty fortunate. But it is such a rare disease, I have to explain myelofibrosis. They say what’s that, and I say it’s kind of like leukemia but red blood cells. I know my primary doctor said Nick, in 17 years you’re my only myelofibrosis patient and probably before I retire, you’ll still be my only myelofibrosis patient.

Fortunately, people like Dr. V. out there, his videos were so helpful for me early on, and I really do appreciate the senior physicians in this field. They’ve been so gracious with their time to get out there and help educate us. It really blew me away to have access to those types of materials because there’s so many questions.

I really appreciate him even being on here today; it’s so impressive.

Beth:

Great. Wow, Nick, that’s so encouraging to hear about how you and your wife got the community involved and really brought awareness to such a rare disease. Dr. Verstovsek, how broadly within the oncology community, how aware are they of MPNs? There seems to be other cancers and such that have a lot more attention.

Dr. Verstovsek:

Over the last ten years, much has been done on the awareness of these conditions for the physicians themselves. You may know that for example, one of the major meetings, the professional meetings in the United States is American Society of Hematology meeting that is always done at the beginning of December. And I tell you that ten years ago, there was no session on myeloproliferative neoplasms or MPN.

[00:49:00]                  

No educational sessions, no scientific sessions of significance of all; it was neglected completely. We changed the field completely from 2004 on by the discovery about what is problematic, the JAK-Stat pathway abnormalities, these biological abnormalities in all the patients and all the associated genetic abnormalities that leads to progressive disease. We changed the understanding of the disease. That led to development of new medications, developing new prognosis coding systems, improvements in our ability to manage patients. And now, I should be proud probably that it is not as fast as we would like, the MPN is at the same level as any other more serious conditions like acute myeloid leukemia. We have full fledged scientific sessions on MPN on its own, presentations, oral presentations.

I would say that people in the field, because this is relatively new, still, are hungry for information; the education sessions are full. Much more can be done on education of the physicians. So it is coming there, but it is a slow process, educational process on the patient side is in parallel being done to educational professionals.

Beth:

Wow, that is great. And it’s encouraging to know that the MPNs are getting the attention that they should be getting. Lindsey, I wanted to ask you, do you feel that focus on MPNs are being overlooked because of more prominent advocacy with these other conditions?

Lindsey:

I would say that it’s similar to what Dr. Verstovsek was saying. I’ve personally been at the American Society of Hematology meeting myself, and I’ve been at a lot of other – participated in some other meetings recently.

I’ve started to look more – obviously, given what I’m doing now with the registry project in the media, there’s definitely a lot more focus on MPNs than there probably once was. I also participate in some activities in Washington, D.C. having to do with the rare disease organizations there; there’s a few different rare disease organizations. So the MPN Research Foundation is trying to participate in activities like that to make sure there’s continued focus on MPNs there.

But you know, I think that we can never do enough, really, when it comes to a rare disease. We all have to play our part and keep it at the forefront of people’s radar because until there are better therapies out there, we can never stop.

Beth:

Wow, and that is great to know that the MPN Foundation is really getting more focus with the rare diseases and the work you’re doing in Washington. In fact now, I’d like to show a quick little video. There are a lot of people in the MPN community around the world that support MPN awareness and they’re doing great things. This short video will give you an idea of who those people are out there. So, I hope you enjoy this video for a few moments.

Beth:

Alright, so did you guys catch Nick in there? We’re hoping to hear from now we’re going to run out of slides because there are so many folks out in the community doing such great things, and that was real cool, Nick. Lindsey, I’m dying to ask you this question. myMPN Registry; we are all really super excited about this from the MPN Research Foundation. Can you talk a little bit and tell us what it is and what the goal is?

Lindsey:

Sure, I’d love to, thank you. So, as we’ve talked about on this webinar, there’s a lot of different experiences by each patient with an MPN.

Some people live with it for a long time, some people get a diagnosis that comes out of nowhere and it advances quickly. There’s lots of different paths that can be followed by an MPN patient. And one of the things that we’re most focused on, as I’ve stated previously, is to try and get some therapies that can help the patients regardless of where they are on that pathway. We said to ourselves, how can we better understand the pathway itself because each person’s experience is different.

People have different symptoms, they have… some of their symptoms are in their blood counts, some symptoms are more depression or they may have itching, they may have some other brain fogginess; different things. Everyone has different combinations.

So we wanted to understand that, and what we decided to do was put together what’s called myMPN. It’s a registry for patients to go in and share their experience. And in doing so, they can help to change the prognosis of all patients. Actually in the slides that you ran, there was a quote from Helen Keller and it talked about it’s not just one major mover or shaker; it’s actually everybody in the process along the way. That really encapsulates what is going on with myMPN.

We need patients each to go in and share their individual experience. We would love it if they would not do it just once but many times; keep coming back to the registry. So, the registry is structured so that we gather the information in a primary survey that has some history, background about an individual, their diagnosis, a little bit about their history and treatment, the drugs or therapies that they’re using.

But then there are additional surveys that we invite the patients to come back and fill out again and again, which collect information about what’s changing. So, there might be an event that has affected their health. Maybe they had some sort of a thrombosis, or a pregnancy, or it could be something related to their MPN or something unrelated. Then there’s another third survey called How Do You Feel Today, and that’s where we really want to understand the patient’s whole experience with the disease; how did they feel today versus how will they feel next week. Are they getting sleep, are they eating? Are they having a lot of fatigue, are they itching?

The idea is that for the many patients that we gather this information over a long period of time, then that will start to help us to understand the diseases better and over time, hopefully we can figure out if there are triggers to the disease advancing from one stage to another; trying to help to put together some of the pieces of the puzzle that currently aren’t available to researchers in the labs and in the hospitals.

We’re hoping to augment the research that’s already going on by helping to provide those researchers and doctors with day-to-day experiences of patients. So it’s a really great way to involve the patients directly in the direction that research is having.

Beth:

I think this is fabulous. Is this up and running now? Is it accessible?

Lindsey:

Yes. We launched actually earlier this month in connection with Blood Cancer Awareness Month. I’m humbled by the response; it’s just been fantastic to see how many people have really been involved and engaged and coming back to the registry.

Beth:

That is wonderful. How does someone get involved? How do they sign onto this?

Lindsey:

We have a dedicated website for the registry; it’s www.mympn.org. And on that web page they will see the link through to begin the registry process. The first thing that a user would do is set up their privacy settings. We liked the platform for this particular registry setup because it enables each patient to customize their privacy settings.

Some patients are very comfortable sharing the information about their health history and background, helping to contribute that information toward the scientific process. Some people just want to record it for their own future reference, and that’s perfectly fine.

Either way, we’re just glad that people are getting engaged. The system, myMPN system, actually does have that flexibility so the patients can determine what information, if any, they’d like to share with the researchers and the research process. That’s the first step; you set up your profile for your privacy settings, and then as I said, you start to go into the survey where you talk about your history with the disease. And then we encourage you to come back and fill out the other surveys on an ongoing basis.

Beth:

Great. Well, I signed up so I’m really excited that I can be a part. Dr. Verstovsek, I wanted to ask you, you’re on the steering committee of myMPN, one of the doctor’s registry.

What kind of impact do you think this is going to have for you and the way you practice medicine and make decisions and deal with patients over the next few years?

Dr. Verstovsek:

This is a very significant step forward. Look, what we know about the current conditions, like for example polycythemia vera. Let’s talk about polycythemia vera. You have in the literature assessment of the outcome of the patients that were referred to tertiary centers in the consultations. So they would come to Mayo Clinic, or to MD Anderson, or Moffitt or any other large academic centers. And there would be possibly let’s say 500 patients with polycythemia vera that were seen over the last 20 years.

Academicians would analyze them from the time they arrived and what happened with them with therapies, and you would come up with some knowledge. But that is such a small, small part of the larger community of polycythemia vera patients. There are possibly about 100-150,000 polycythemia vera patients living with the condition here in the United States.

And what does it mean to analyze the outcome of the 500 patients that were referred to you in academic centers? It means a lot, but not too much in the larger picture. So if we have a way of having a registry where multiple, multiple people, patients from – many patients from a larger group of patients, not just those that are seen in academic centers, can participate. And we can learn how they were diagnosed in a community setting; what did the local doctor do?

What symptoms did they acquire during their lives? What therapies did they receive, and why and what happened with those therapies? Any complications with the thrombosis? Any complications through the pregnancy? Those are the issues that are mentioned already. What led them to be referred to academic centers?

We can enlarge our knowledge, better our knowledge about the disease conditions; time to diagnosis, time to progression, management in community setting and the relevant new interventions and new ways of assessing needs of the patients, and understanding life with PV, or life with ET, or life with myelofibrosis on a larger scale and see where to intervene and how in the future.

Beth:

And in some ways, this really seems to overlap personalized medicine. We’re now not looking at the one scenario for PV or myelofibrosis or ET. We are looking at hopefully a huge group of MPN patients and putting those pieces in the puzzle, as we said Lindsey.

Dr. Verstovsek:

And let me add – this is really good. This is an excellent comment. Because we these days think a lot about the genetic complexity. There are patients with myelofibrosis or any other conditions that differ based on genetics, as I mentioned earlier on. But there are patients with myelofibrosis that present with anemia only, patients that prevent with very big spleen and poor quality of life.

There are different ways of people progressing or presenting with a condition not only based on genetics. What is the experience of patients that have only low blood cell count versus those that have a very big spleen; how did they fare? It’s clinical assessment and quality of life assessment and blood cell count assessment. We don’t really need to engage in extraordinary tools to learn. Genetic is one part of it, but it is much more we can learn from our on practice on the larger scale.

Beth:

Dr. Verstovsek, is there really a difference between this and an observational study?

Dr. Verstovsek:

There is some difference in that observational studies are usually much more focused in a shorter time period in a selective group of patients, in academic centers usually, with much more scrutiny of the detail. So, if you have an observational study in polycythemia vera, since we’re talking about polycythemia vera, there is such a study; it’s called the REVEAL study. There is also observational study for patients with essential thrombocythemia and early stage myelofibrosis called the MOSS Study.

So, a limited number of patients with very dedicated focus to see patients periodically, collect all the data of what happens to them all the time, because they are followed by clinicians and the researchers and nurses; this is a full fledged clinical study. Without intervention, just to see what happens with them; what symptoms develop, what complications they may have with other medical problems, what happens when they’re hospitalized and why, what the reasons are for intervention for their disease.

What is the effect on their work, ability to communicate with the family, engagement in social encounters. So it’s much more focused, perhaps more in detail and in a short period of time. But it does very well complement the registry, which is much broader and for a much longer period of time. So, I encourage patients to participate in both efforts.

There is complementation between the two, and certainly encouragement from the academic and local doctors to learn from these efforts.

Beth:

Doctor, what is the criteria to participate in an observational study?

Dr. Verstovsek:

Unlike the registry where really we are trying to include everybody who has the disease at different stages to see what is happening with them, registries are usually focused on the patients like the Moss Study; I mentioned it’s for patients who have essential thrombocythemia that requires therapy; and for patients with myelofibrosis that do not require therapy. So it’s a concerted effort to understand much better in detail particular groups of the patients. So there is eligibility criteria for participation in some of these observational studies, unlike the registry where we really like to have everybody.

Beth:

Alright. And of course now this leads me to clinical trial. We hear a lot about clinical trials. Could you briefly describe for us the difference between a clinical trial and an observational study?

Dr. Verstovsek:

Absolutely. And see, while I was giving an example of an historical analysis of patients in academic centers that leads to information how to manage patients and what to do about them. But these are the patients who are referred to academic centers, usually – most of the time – because they are not doing well and there is a need for intervention. And most of the time, we talk about treating patients that need to have something corrected.

They suffer from anemia, they suffer from a blood clot and this is where we intervene, and this is where most of the work in academia is focused on. This is where we do clinical studies. Clinical studies in MPN, most of the time and in the United States in particular, are focused on correcting something that is wrong; improving quality of life, decreasing the spleen, improving the anemia in ET or PV.

We would like to treat people for what they suffer from; high platelets, high red blood cell count, big spleen, symptoms. Intervention studies in myelofibrosis for example are needed as we try to prevent another clot in patients with ET and PV. So we are moving from interventional studies to prevention studies. And to get proper assessment of those patients in need, observational studies are needed to learn about the experiences.

A registry is needed to learn about a wide spectrum of patient experiences for us to identify groups that would, for example, benefit from prevention rather than waiting for them to suffer and then prescribe something to correct it. So prevention studies will be major developments, in my view, from observational studies to see where we need to intervene once we observe.

Beth:

Very interesting. I had not even heard of that. That is fabulous.

Both Nick and Andrea, you have both participated in trials. And Andrea, I would like to go to you first. You’ve been in several clinical trials. What was your journey, and what was beneficial in participating in those?

Andrea:

Well, frankly the whole point of my participation was not only to feel better and maybe arrest the disease to an extent, but I felt since it was such a rare disease I had an obligation to try to advance research by using me as a live guinea pig. Instead of donating my body to science later; let’s try to do something now. Of course I had selfish reasons, as well. What happened with the early studies which were done nine years ago or so, several of them just were very toxic for me, and for different reasons.

But different things happened; a couple landed me in the hospital. But I knew there was something out there, working with Dr. Verstovsek, working with my local hematologist; I knew that if I didn’t try and didn’t do things, that I certainly wasn’t going to get any better. So, when we hit on CYT387, which I bugged Dr. Verstovsek about because I read about it, and I said it sounds right for me; he said yeah, I’m gonna get it, I’m gonna get it.

He finally did. It worked for five years. The company was bought out by another company. I have a similar drug; it doesn’t seemed to have worked as well but for five years I’ve been transfusion independent, which is huge.

While my anemia has not been anywhere near normal, it’s certainly functional and I’ve been great. Now we’re looking for something else. I’m a perseverant person, and the first couple of trials didn’t work but I didn’t die, and I didn’t get any worse. And the fourth and fifth trial did work, so I think I have to encourage people to not give up. We’re all different, and we talk about that in our support group. Everybody is different. We are so individualistic in this disease that we can listen to other people, but we have to really listen to our bodies and ourselves.

So now, it’s that period of kind of treading water; what do we do next? There are some things that Dr. V has mentioned, there are some things that I’ve been reading about that I’m going to quiz on him when I see him next. And so it’s a little discomforting right now because something has to happen.

 But I’m confident and positive that there will be something out there, but if I don’t try, we’ll never know and a patient behind me – we have people in our group who are 20 years old and 30 years old. They’re panic-stricken. So hopefully I can help them, maybe; if I don’t someone else does.

Beth:

You know, Andrea, you’re very inspiring. Me kind of being new to the game, too, it’s very inspirational to hear about your perseverance and your attitude. I love the idea that you’re also there for the younger people in your group to show that this is the journey but it’s working, and there’s hope on the horizon. Nick, if you could tell us a few things, a few thoughts about your journey through your clinical trial and if there was a benefit?

Nick:

Yeah, sure. It’s kind of interesting for me initially when I was diagnosed, the local doctor said well, you’re so lucky; you have Moffitt right here in your backyard. So I went to Moffitt Cancer Center, and they’re very good but the hematologist said basically the same thing that the initial doctor who did the diagnosis; well, you’re a good candidate for transplant, just wait a year, watch and wait a year and then go to transplant and so be it. But you do the research, and transplant is a pretty tough deal.

When I went to Moffitt, basically that’s what the doctor said, is we’ll see you once a month or every other month and sometime next year you’ll go to transplant. I said doctor, I can’t just sit around and wait and just sit back and placidly have this ticking time bomb hanging over me without trying to do something. And like Andrea, I also felt I owed it to the other patients that maybe being part of a trial that we’ll learn something.

I was hoping – my goal was to try to postpone my transplant for several years. But I said being part of the trial, maybe they’ll learn something good or bad that will help other patients as well. And that’s where I was very fortunate to land at MD Anderson with Dr. Pemmaraju.

They set me up on azacitidine and Jakafi. Moffit’s pharmacy doesn’t even carry Jakafi. So, the No. 1 tool in the toolbox for MPN patients, they don’t even have it there. That’s where we did the trial, and I think with the trial the one thing that people need to know, you’re under a much higher level of scrutiny. Dr. Pemmaraju at Moffitt, they’re having me come in every 30 days for blood work, 60 days to visit with the doctor. Pemmaraju, he’s seeing my stuff every week; they’re looking at my numbers. I go fly out there once a month to meet with them.

And so you have an extra layer of coverage. And ultimately, it was Dr. Pemmaraju who said hey, Nick – by the way, CAL-R, JAK2 was my mutation, which also people need to know who’s doing what. But in October, Dr. Pemmaraju noticed my BLAST had spiked from 1 to 5. He said Nick, you’ve got to go for transplant because if it turns into AML, your prognosis really gets a lot worse.

And I’ll always remember the look on his face. He just looked at me and said, time to go. That’s why I think his higher level of watching me gave me that sense because there is some controversy out there as to when to go to transplant. When do you go? Do you wait? Is there a certain number you have to hit?

I felt that his advice, based on all the doctors I had met with, was very right on point and I appreciated their – there’s a great group of folks there, and I certainly think that my success – and I don’t know if Dr. V. agrees, but me being on Jakafi, actually they kept me on it through the transplant; I think that helped me because I’ve had a fairly good transition through the transplant process. And I think it was based on the work that Dr. Pemmaraju did.

Beth:

Great. Nick, you’re very encouraging. Dr. V, since Nick brought that up, how do you feel about that, that he was kept on Jakafi?

Dr. Verstovsek:

I would say that both Andrea and Nick have amazing stories to say and to tell us their experience and to learn, and really inspiring stories. I’m glad that there was a time period to enjoy some good quality of life and control of the disease for Nick. But in this tough disease, myelofibrosis, it can be controlled for a long period of time but it does change as the medications really don’t work forever. And sometimes it is necessary to go to transplant and we treat patients up to the transplant with Jakafi to maintain the benefit that might still be there.

After the transplant it’s not necessary anymore, of course. But that is one of the experiences that people need to understand that there is a potential for medications to control the disease, either through clinical studies and the first option may not work, the second may not work and there are always – and we try to have those here – multiple other options through conventional medications or through investigation medications to help patients. And if the transplant is necessary, we will do it when the time comes and it is a personal decision most of the time.

It’s not really one number; it has to be between the physician and the patient.

Beth:

Absolutely, absolutely. Lindsey, I’d like to ask you the last question, and we do have a few questions from our viewers. We’re talking so much about clinical trials and raising awareness, how do we do that, and how does raising awareness affect the clinical trials? I know like barely anything about clinical trials.

Lindsey:

Sure, that’s a great question. In fact, one of the things that we try to do at the MPN Research Foundation is to let people know about clinical trials that are going on so that to the extent that someone is looking for something better, kind of like Andrea was or has been. Maybe they haven’t been made aware by their own doctor of an ongoing clinical trial.

And by using our social media and our website, etc., we can make people aware of that. I think that’s – it’s a great way for people who are patients but also I think that it’s important for patients to understand the message that Andrea delivered that I think was so eloquent. Which is unfortunately, drugs don’t come onto the market without brave patients like Andrea and Nick who are willing to put themselves out there and take something that is yet to be approved by the FDA. Because the FDA has very specific standards and they scrutinize the trials very carefully. But at the end of the day, we need patients to volunteer for these trials.

I think it’s wonderful when patients do that, and it’s even better when the results are great, obviously. But I think from an educational standpoint, we as an organization and I know others try and help people to understand what their options are, what the process of a trial is. We’ve actually in the past put together graphics to help people understand how trials progress. We actually have been involved ourselves in discussions with the FDA on how trials can be more focused on the patient experience.

So I think that things are definitely going to improve, and hopefully we’ll see more drugs that are available for patients that will provide more relief very soon.

Beth:

That’s very encouraging. I absolutely agree with both of you how people like Nick and Andrea, and could be myself as well one day in the future; we can’t move forward. We don’t want to be stuck and not be able to have those results. I’m going to shift gears a little bit. We’re ready to take a question. Dr. Verstovsek, this question I believe is geared for you, and I’m going to go ahead and read it. Dolf from Holland is watching.

How is research internationally organized? Dolf goes on to say lots of trials with MPN hematologist around the world, and we can find them on clinicaltrials.gov. But is there also some specific research in some countries that’s not registered at that site? Is that something you can address?

Dr. Verstovsek:

That’s a very good question. There is an attempt by clinicaltrials.gov, which is actually the federal site, to collect all the clinical trials that are being conducted not just in MPN, obviously, but in any other condition. And the effort is really significant with the prospect of utilizing that for patients as well to identify the sources, if not only for the physicians. It is really the professional side but the patients can search that as well. Perhaps it’s too cumbersome sometimes to find information, but underlying the attempt is very well received at least in the professional circles.

If there are any other studies in other countries that are not registered, of course it’s a possibility this is the Federal Government of the United States. I am not aware, didn’t really look into that, whether other governments in Europe – and I would say some they do, maintain something similar for their own countries like in Germany or France.

This is, after all, one of the best sources of information, clinicaltrials.gov, for clinical studies.

Beth:

Great, thank you so much. We’re going to take one more question; unfortunately we’re almost out of time. But we have another event coming up October 7, and we will definitely answer many of these questions that have come through tonight. And in fact, Dr. Verstovsek will be on that panel as well, on the upcoming one. I do have another question for you, Dr. V. It’s from Julie. Do you have any tips for patients to educate their primary care provider about MPNs? And she said more specifically, PV.

Dr. Verstovsek:

The information that is available to the patients through the MPN Educational Foundation or through the information that can be gathered from the academic websites for the patients typically is organized very well for anybody to understand it.

I have patients that are engaged with us together, as we said, in that educational effort for all participants to be at the same level. That means not just us in a referral center or patients, but also referring doctors. So the best information to a primary care doctor, and I assume that was what the question was about, the local oncologist; that is delivered by us as experts in MPN and by the patients.

By bringing that information to the attention to a local doctor is valuable. There is rarely any doctor that would not appreciate so much the involvement of the patients on the part of education, and bringing the new information to the doctor. Look, the local hematologists and oncologists, that’s a hero for me.

That doctor, a female or a male, has to take care of not just the PV; it has to take care of patients in brain cancer and kidney cancer and lung cancer; both of the perspective of life and professional commitment in front of you for that particular doctor. That is the doctor that is doing all of this at the same time, and has to catch up. So we have to also realize that it’s really difficult to follow all the updates and all new developments in the field for PV or any other MPN. So, I know that doctors appreciate when the patient is engaged and brings information to them.

Beth:

Excellent advice. Julie, when you asked about their primary care providers as well, I’m sure Dr. V. feels the same way; we can take a look at Andrew Schorr and his wife Esther who created and head up Patient Power. Esther is very vocal about being a very educated care provider.

And through everything we’ve talked about today with myMPN registry or the MPN Research Foundation, or all the things that Dr. Verstovsek brought up about how he educates his patients, the primary care providers definitely should be in that conversation. Those things are all welcome.

Well, we are just about to wrap up. We’ve had a really great discussion here today, and I would like to get some final thoughts before we say goodbye. We are a little pressed for time. Nick, if you can give us a few quick, final thoughts and we’ll just go around after that.

Nick:

Well first, Beth, great job on the hosting. It was very impressive, and glad to be able to participate. And certainly want to thank all the panelists to try to keep moving folks forward. And hopefully some day the people behind us won’t have to worry about the same issues we’re dealing with today. And appreciate Dr. V. taking the time especially, and all the great work that his team is doing, too. So, wish everybody the very best, and thanks, and great job, Beth.

Beth:

Thank you, Nick, and right back at you; it’s been a pleasure having you. Andrea, some final thoughts from you?

Andrea:

Yes, thank you everyone for participating, it’s been great. It’s my first time. I would like to say that one thing I found successful was to print some pamphlets up and to distribute to my doctor and leave them out so people are aware of our meetings. And also, to really encourage people to look very seriously into clinical trials and going to an institution like MD Anderson that specializes in their disease so that they can get the best care and educate themselves the best.

Beth:

Thank you, Andrea. Those are great words of wisdom and we appreciate all of your feedback, having been in this journey for almost 20 years. Lindsey, can you give us a few final thoughts?

Lindsey:

Sure. Thank you very much for including me in this conversation; it’s been wonderful to join Dr. Verstovsek and Andrea and Nick.

I encourage anyone who has not yet visited myMPN to please visit us at www.mympn.org. If you have any concerns or questions, please don’t hesitate to reach out to me. I encourage everyone, like Andrea said, to try and get involved in your care, whether that’s through myMPN, through joining a clinical trial, and certainly just being an advocate for your own health and going to go visit those doctors armed with the information that you can.

Beth:

Thank you. Great words of wisdom. And again, we are very excited about the myMPN registry, so thank you for sharing that today. Dr. Verstovsek, we appreciate you being here. Some final words that you can give to our audience?

Dr. Verstovsek:

I really appreciate you having me on the panel; it was a wonderful experience.

And certainly what we have achieved together, I’m sure for many patients is to engage, engage and be educated, learn about what you have, learn about the abilities to help you if you are not already. Be an active participant because these conditions are there to stay with you; we don’t have a cure yet. We are working toward it. But life can be good, life can be controlled well. We have means and we are trying to do our best. So be an active participant with the local doctor, with expert. Make the most out of it and if you need a second opinion, search for it. Basically, do not give up. Be your own advocate, if you like.

Beth:

Wonderful, and I couldn’t agree with you more. It’s just very inspirational and those words will resonate with many of our viewers, I know.

Thank you, I’ve enjoyed speaking with such experts on this panel today, and thank you for the words of wisdom and best of good luck and health to all of our viewers, and Nick and Andrea. Thank you.