Miami Cancer Institute's High-Tech High-Touch Approach
Join our experts for a panel discussion on Breast Cancer & Gynecologic CancerOriginally Webcast: Thursday, October 21, 2021 | 5:30-6:30 PM
Topics to include everything from breast cancer prevention, to state-of-the-art holistic treatments, and advances in gynecologic cancer care, including robotics and therapeutics.
Good evening everybody, thank you so much for joining us this evening. Welcome to R. M. C. I. Physician webinar. We're very excited that you all have taken the time to join us here today for our panel of experts on Miami Cancer Institute's high tech high touch approach. My name is Christy flattens, I'm with baptist health south florida physician business development, I'm very happy to introduce to you all our moderator, Dr Jane Mendez. Dr Jane Mendez is our Chief of breast surgery at Miami Cancer Institute. She is board certified by the american Board of Surgery and fellowship trained and new york's memorial Sloan Kettering Cancer Center. Dr Mendez does specialize in the treatment of breast cancer and does perform all types of breast surgical procedures. She received her undergraduate degree from Harvard University and her medical degree is from Mount Sinai School of Medicine in new york. Prior to joining Miami Cancer Institute, Dr Mendez gained extensive experience as a surgical oncologist at boston medical center where she served as president of the medical and dental staff. She has contributed, contributed to notable breast cancer research and her findings have been widely published. Happy also to share that dr Mendez is passionate about education and advancing breast cancer awareness and prevention in the community as well at national meetings. She is a board member of the American Society of breast surgeons as well as the Medical advisory board for the promised fund. She does co chair of the health equity and disparity committee of the american Society of breast surgeons with that. I would like to turn it over to Dr jane Mendez so we can start our webinar. Thank you Christy for that kind introduction And it's my pleasure to welcome you all to this evening's webinar as you say, Miami Cancer Institute high tech approach. So again thank you for joining us And now it is my a privilege to introduce dr john Diaz is the deputy chief of Gynecologic oncology and lead physician for clinical trials and technology oncology and Miami Cancer Institute. His poor certified and obviously he works here in Miami Cancer Institute. He provides comprehensive care for women with endometrial, ovarian cervical and other times of the wayne cancers has extensive training and experience in minimally invasive surgery. He completed his fellowship training in memories from getting cancer center in new york. And there he earned the award of the department of surges chairman and he served associate professor of department of gynecology at F. I. U. As he's also is the leading physician in the excellence of minimally invasive gynecologic surgery and he does a lot of robotic surgery and actively participates an important clinical trials. His research interests include, among others, innovating cancer techniques including hypothermic interpret o'neill chemotherapy and immunotherapy. Furthermore. He has received significant awards for his research he received in $2019 million in grants for immunotherapy and part inhibitors for treatment of cancers and he's been also what they published as you can see here. So needless to say it is my honor to introduce john as our first speaker in this panel. And will he be addressing an ecological oncology the M. C. I. Difference. So john thank you for coming today. Next we have dr Calla Gerbera. She is another gynecologic oncology. She just joined us a Miami Cancer institute. She came from the Mayo clinic where she did her fellowship training there. She also worked as an assistant professor in gynecology, the Mayo clinic. She actually is passionate about gynecological oncology as well as research and wants to help patients at a brother level. She has presented at numerous national and international conferences and has been published in peer reviewed journals. Furthermore, the caldera did some research fellowship when she was at the Mayo clinic and earned a significant words for her work on and hence recovering an ecological surgery and which revolutionized as resulted in models for errors or enhanced recovery after surgery. She believes in the compassionate approach to cancer care and the importance of responding to the patient's needs and his work as a gynecologic oncologist is important to help navigate their families in these challenging times in their lives. And she will be addressing the issues of the outpatient hysterectomy A. K. A same day in his directory to follow. I have the honor of introducing my colleague start Mautner breast surgical oncologist who's also board certified surgeon. She has expertise in breast surgical oncology and obviously works at the Miami cancer institute part of baptist. She specializes in all sorts of the different breast cancer options, including skins, prime mastectomies and nipple spry mastectomies. She completed her breast surgical oncology fellowship and memories from curing cancer center in new york Manhattan and had the general surgery residency at new york presbyterian Cornell medical center in new york. She also completed a research fellowship also memories from getting cancer center where she looked at tailored ways to look at women with lobular carcinoma inside too as well as issues having to do with life after contra lateral prophylactic mastectomy. She earned her medical degree from the University of Miami and she's a member of multiple uh society organizations including the Society of Surgical Oncology, the americans associated breast surgeons and the Association of Women's Surgeons. And she will be addressing Miami Cancer Institute high tech high touch and the last speaker will be dr ana Sandoval, one of our colleagues in medical oncology who will be addressing issues pretending to breast cancer prevention. And anna joined us from Miami from the Miami University where she actually received her medical oncology training. She actually is interested in systemic therapies as well as research and she's very active in research practice as well. And she leaves the efforts in a breast cancer prevention clinic which will be addressing at this time, She has been widely published as well and has a keen interest in clinical research as well. So banana will be talking about breast cancer prevention. So with that, I'd like to have john because of this evening, so john uh looking forward to hear your talk organica, logical oncology, the emcee difference. So thank you john thank you jane for that introduction and thank everyone who joined us today after a long day of work. So I'm john Diaz, I'm the chief uh Joanne oncology here at M. C. I. And in the next 8 to 10 minutes I'm going to try and discuss a little bit of what we do here uniquely for our patients with Jonah in oncology. So we have many people joining us from outside of south florida. So this is what our building looks like. We're located here in Miami florida. This is the Miami Cancer Institute, it's 500,000 square feet, making it the largest cancer center in the state of florida over 100,000 square feet of that is dedicated to clinical research. And we're also members of the more Sloan Kettering alliance, which is something I'm very proud of. Um and we're the only members of the alliance outside of the Northeast. A lot of people ask me john, what are the benefits to baptist health in south florida with this Sloan Kettering alliance and one of the things are the treatment pathways we all know that medicine is not black and white and there's a lot of great and if you look sometimes at the National Cancer Care Network recommendations, they can range from surveillance to chemotherapy to chemotherapy with radiation therapy. And so with the help of Sloan Kettering, we've helped to develop our treatment pathways which mirror what the recommendations are from Sloan Kettering. We have a group of 61 oncologist making us the largest group of junior college in the state of florida trained from Mayo clinic. Sloan Kettering University of California Irvine University, Miami johns Hopkins. So we all brought our own bias to the division. And so this has been really helpful for us to concentrate and come up with treatment plans. Again, parallel the recommendations patients would get at Sloan Kettering. The other big advantages clinical trials. Uh many of the south florida know that oftentimes patients of means if they got sick they would often leave south florida and go to new york or boston or texas. Uh but most patients can't do that. And so by partner with Sloan Kettering, we can bring the clinical trials offered in new york right here to our patient population in south florida. And then the other component is educational partnerships. We've been very fortunate before Covid to bring down many national international speakers who are attending that Sloan Kettering to speak out our symposiums. Likewise, many of us have been invited to speak at Sloan Kettering on our expertise that's going on robotics and high FEC. And this is continuing the covid, so this has really helped to increase access to some of the experts in Sloan Kettering and a partner um presentations. So the next 7-9 minutes and James going to keep me on course. I'm going to talk a little bit of arguing oncology program. What are some of the novel therapeutic options we offer here? It may be cancer institute and perhaps the most important thing is the M. C. I. Patient experience. So robotic surgery is something that we are all very much familiar and skilled with. I had the ability to be at Sloan Kettering wound. They first introduced robotics back in 2000 and seven and so I've been using the robotic platform um for over 10 years. And as many of you know, robotics allows us to perform complex minimally invasive surgery allowing patients the benefit of surgical approach but with less pain, less blood loss and a quicker return to um work. And so this is a robotic hysterectomy instrument. You see there is what's called the vessel sealer and that is a bipolar, any device that both seals and then has a knife that can cut through. And so again all of us are pretty well equipped and familiar and experienced with robotic surgery. Most of our surgical procedures is performed via a mini invasive technique. And about 50% of what I do is benign gynecology and so complicated G. Y. N. surgery referred to us because of our surgical expertise and it's something I enjoy doing. And again taking these surgeries that would otherwise be done to be an open approach through minimal invasive approach given the benefits of going home the same day. And my partner dr caligari is gonna talk more about the same day hysterectomy. Yeah. Less narcotic use. And for those cancer patients, they're able to start their adjuvant therapy sooner than they would through a traditional incision which we know has demonstrated improvement in outcomes. Yeah. So robotic expertise is something that we're really proud of here at M. C. I. South Miami Hospital, which is part of the baptist health system is the only hospital in south florida that the Center of excellence for minimum invasive gynecologic surgery actually not baptist main not immersed in Miami and not clean clinic. No other hospital in south florida carries this designation. And I lead this program and it's really important. You know, we capture our metrics, we prospectively look at our outcomes to ensure the best possible outcomes for our patients. And although staff from the hospital is one of our smaller hospitals and health system, we perform more robotic surgery in this hospital or other hospital in the state of florida. And we're very proud of that fact. Yeah. One of the things that robotic surgery allows us to do is to perform lymph node dissections through a minimally invasive approach. And here in my right hand you see are the robotic scissors who that have energy in my left hand. There have the bipolar advice. So we've opened up the retro peritoneum and we're gonna perform a routine lymphatic ectomy. And as we know, lymph node metastases. Perhaps one of the most important prognostic factor for G. Y. N. Cancers particularly in cervical and endometrial cancer. And in the past we would perform a complete public lymph node dissection which you see here. Um But really when you look and see particularly endometrial cancer which is the most common G. Y. N. Cancer, most women present at an early stage. Most women are low grade tumors And their risk of life. No metastases is only about 3%. So we're performing these extensive lymph node dissections and women, despite the fact 97% of women really derive no benefit from this procedure. And again we're all excellent surgeons and neurosurgeons things to have their morbidity. But the reality is these procedures have operative time, have increased blood loss, have a potential for vascular or nerve injury. And so when I was at Sloan Kettering, I worked with the breast team, particularly married Gemignani who was a german oncologists who later developed an interest in breast cancer really transition her practice to breast surgery. And we borrowed from the breast team the idea and the concept of sentinel lymph nodes. And so this was one of the first papers every published United States looking at the feasibility of sentinel lymph node mapping in early stage cervical cancer and this for a long time was the paper that was cited in the N. C. C. N. As this move from experimental into standard of care and this is a sentinel lymph node dissection being performed robotically. You can see here we're in the white light. Then we injected a green dye into the cervix. That green dye then travels to that first sentinel lymph node. You can see that here when we toggle to our near infrared. And so we're able to identify that first draining lymph node. Were able to remove just that one lymph node thereby decreasing the morbidity of lymphedema, decreasing your risk of vascular nerve injury and actually increasing our detection rate of lymph nodes. Because these lymph nodes then go to pathology and they're looked at differently. Regular lymph node has looked at they cut it once they stay in it they look for any evidence of metastatic disease and move on with sentinel lymph nodes. They do additional pathologic evaluation. And because of that we're able to identify additional metastatic disease that would have been missed. And really ah ha moment you have with this I had a patient that we did an article in the Miami herald who was an early stage in the mutual cancer and underwent sentinel lymph node mapping and had her lymph nodes being evaluated routinely. The way the pathologists normally do. They would have missed the metastatic disease was inside her lymph nodes instead. Because of the ultra station protocol we identified she went on to receive her abdomen therapy and I just saw her two weeks ago and she completed her five year disease free interval. And this is someone who would have initially missed would have likely rickard and would have been puzzled by an early stage endometrial cancer occurred. So these are one of the things that I brought back from new york to south florida. All my partners are very well skilled in this. Uh And again it's one of the metrics we looked through throughout SK alliance. One of the unique things that we offer here at M. C. I. Is hypothermic intraperitoneal chemotherapy and essentially what this is at the time of a cider reduction procedure when you remove all the cancer, you then do a heated bath inside the peritoneum cafe with chemotherapy. And this has a couple of different advantages. One is normally after a big surgery patients wait 4 to 6 weeks before starting their adjuvant chemotherapy and study from Sloan Kettering. And the Anderson demonstrated that a lot of times the cancer may have grown back in that time period. So now we're giving chemotherapy right at that moment it's after the surgery removed all the tumors. So the tumor burden is less than the chemotherapy has to work by heating. We get deeper penetration into the tissue. And this is something that I've been performing since 2012 and really were one of the few centers in South Florida that has such expertise in this. So I did an initial pilot study presented at Sugo looking at our initial experience uh for recurrent ovarian carcinoma. And these were our survival outcomes and these were in heavily pre treated women. So this was very encouraging and based on this, me and one of my co fellow from Sloan Kettering, along with a group at Sloan Kettering developed a randomized phase two trial looking at High Pick. And this was run through our alliance. Again that clinical trial we have, it was ourself Sloan Kettering actually the Mayo clinic also participated and this trial was presented at ASCO two years ago and just came to publication in Jae SEo which for us is oncologists. This really is the Holy Grail for where we would like to publish our research. And so this is you know, proof of concept that the alliance can run clinical trials even a randomized controlled trial and can get published in the most prestigious of oncology journals. And so we're very proud of this work while we're doing this, a group from the Netherlands presented their work on High Pick in the up front setting for women who underwent new admin chemotherapy and this demonstrate a progression free and overall survival advantage. So this now has been added a standard of treatment for the NCC and guidelines. And thankfully again we have a lot of experience performing this. And so we've incorporated this into our management for G. Y. N. Malignancies. And so we have a party no disease team here at M. C. I. And it consists of myself, I lead this team uh surgical oncology, the colorectal surgeons, thoracic oncology and our medical oncology colleagues. And we treat G one linksys mesothelioma appendices and select colon and gastric cancers. Again we're one of the few centers in florida that offers this multidisciplinary peritoneal disease team which we're very proud of. One of the things that really separates us is our clinical trials program. We have phase one trials. Phase two. Phase three cooperative group trials and I'm very proud of the robust clinical trial program that we've developed just this year and asked what we were part of a Phase One team that presented a novel drug in ovarian cancer that are called ADCS or antibody drug conjugate. And basically these are like a trojan horse. So they have a receptor that binds on the outside of the cancer cell. It then gets brought into the cancer and that's where it delivers its payload. So that's kind of why I use the trojan horse analogy. So this was a Phase one trial which we participate in, we presented at ASCO and in fact this drug has now been fast tracked through the FDA for accelerate approval because of how encouraging the Phase one results are when I'm working. And opening a Phase two trial for this as well as looking at these drugs in combination with other traditional therapies. So again this is our Phase One program developing and being presented at again, the american side of political oncology, which again is our most prestigious oncology meeting. They also presented my face to trial this last year. The parliament results. Uh this is a trial that's looking at immunotherapy in combination with park inhibitors for recurrent cervical cancer. I received a grant for this trial. We've also partnered with florida International University for our basic science component. And actually we've identified a novel pathway called the Fanconi anemia pathway that may be predictive of those women who are gonna respond to immunotherapy. So right now immunotherapy is a pretty exciting treatment for cancers. Um and some of the markets that we use are what's called MSC high pd L. One and tumor mutation burden to help predict which patients is most likely to respond to this. We're working with our colleagues at F. I. U. We've identified another potential bio identifier for who's gonna respond to this therapy. And this trial is ongoing. What are faced through trials and we've had numerous face three and cooperative group trials which have been published and the reason it's so important you see here is research for ovarian cervical uterine cancer is among the most or poorly funded research. And so it's so important to be able to bring these clinical trials to South florida and allow access to women South florida to get the greatest technology and opportunities of these new drugs. One of the things that's so important that has changed the way we treat ovarian cancer is understanding patients and their tumors BRC mutation status. So all women with ovarian cancer are recommended to go both germline and somatic mutation. All women are referred to our team of geneticists here and we have the largest collection of genesis under one roof here at the M. C. I. Will undergo genetic evaluation, the appropriate genetic testing as well as tumor testing to help really tailor their maintenance therapy. Right and again the most important thing is the M. C. I. Patient experience and that includes a multidisciplinary approach. We partner with our racial college team, work very closely with them are tumor board, we have radiation oncology. Present the geneticists are clinical trials team. Our pathologists who have done a fellowship in german pathology, johns Hopkins. So we really have the best of the best here. Yeah our genetics team patients participate in cancer rehabilitation. Doctor Adrian christians who comes from Sloan Kettering leads this program and our patients were getting chemotherapy and a little bit frail. We can refer them to cancer rehab to improve their performance status and also get them ready for a clinical trial that may be available to them. We also have our psychiatry and neuropsychological teams. Again all under one roof nutrition is imperative. We know most women with early stage endometrial cancer don't die from a mutual cancer. They succumb to disease as a result of the obesity that caused the endometrial cancer which leads to diabetes hypertension and other diseases. So it's so important to not only treat the cancer but treat the whole patient. We have alternative medicine program with acupuncture which have been shown to help with pain control, nausea. Our survivorship clinic which is led by dr Beatriz courier which focuses not only on what we focus on in clinic which is your cancer whether your pet scan show of recurrence. This focuses on life after a cancer diagnosis and how to live with that and especially our nurse navigation system. Each patient identified and given a nurse navigator who is another resource for them. They can contact that helps guide them on when is their next appointment? If they have difficulty with transportation if they need help with social worker finance. Our nurse navigators work side by side was in the clinic seeing these patients are community programs like this like our cooking classes or zumba classes, all these things that patients can participate in which it was offered a large cancer center like this and of course pastoral care all this under one roof. So I want to thank you. I know I covered a lot of topics and Jane is probably upset that it took more than 10 minutes but I thought it was really important to just highlight some of what we do here Miami Cancer Institute and what really separates us and the care that we give our patients. So thank you for your attention and thank you jane and clear for this opportunity. Thank you john for such an informative talk. You know about all the things that we can provide here at Miami cancer to from clinical trust research to the bedside as well as all the holistic approach that we have as you alluded to under one roof. So with that it is my pleasure again to introduce our second Panelist. And that's Doctor Syria Calla Gerbera and she'll be talking about the outpatient hysterectomy A. K. A. Of a same day, hysterectomy. So dr caldera. Welcome um thank you very much for attending a webinar today. Thank you for the kind introduction dr Mendez. Uh My name is luke Perry Calogero and I'm a gynecological oncologist here at the Miami Cancer Institute. I am excited to be discussing with you today. One of the important services that we provide for patients which is the outpatient hysterectomy or what we like to say or refer to as the same day. His threat to me, which means that the patients coming in the morning or during the day for their surgery, they have a major surgery, they go home the same day. So the two things that I would like to focus on our first of all, why doesn't matter why, why it is important or what it is an important service and the second element that I would like to be discussed with day is what are the key elements that makes us successful in being able to provide this service in a safe manner to our patient population. So first of all, why do we take great pride in being able to offer this surgery to our patients? So there are a number of reasons and first and foremost that there is an increasing demand in the need for hysterectomy for benign but also for malignant indications and our ability to expedite the discourse of the patient and uh even bypassing the over United States put is in a great position to be offered to be meeting this demand in a more timely manner. In addition, hospital states have been shown to have some inherent risks associated such as increased hostel for infections with multi drug resistant microorganism or increased risk for diabetes and blood closed due to prolonged immobilization. So it has been shown to be a safe practice in terms of outcomes and especially in this day and area. It has also been shown through research to be a cost effective practice and very importantly poses in a position to truly optimize how utilize our hospital resources are inpatient hospitalizations and hospital staffing and importantly, it has been consistently shown that it is associated with high patient satisfaction and while we have been offering this service for quite a while and definitely before the pandemic to our patient population. You can imagine how critical it was during a worldwide pandemic when we were truly very limited in our ability to provide some of the important surgeries that were providing that were especially tied to an inpatient admission. An offer uncle logic based surgery to our patients despite the pandemic, but what distinguishes us and what places us in a unique position to be able to offer the service um safely. So there are three major elements that will be briefly reviewing. The first thing is, first of all, how do we care for our patients pre operatively? And there is a pathway that will be discussing with you call the enhanced recovery after surgery pathway with determines what we do before during and after surgery for the patient. The this is called as abbreviated as ERAS. So the second element of success is the type of surgery that will perform. So not only how we care for the patient very operatively but how we do the surgeries and we are using the robotic approach. The third element of success is the fact that we're able to come together and work very closely in a collaborative fashion across a number of different things and this is absolutely critical. So starting first of all with the first component, the enhanced recovery after surgery. You may be familiar, you may have heard or you might note especially if you're not um working in a surgical settings. So the enhanced recovery after surgery pathway or ERAS is a truly modern evidence based approach to peri operative care that has really revolutionized How we care for our patients. And it was first introduced back in 2011 in Gynecologic surgery in the United States. And I've had the opportunity to be part of the founding team at Mayo Clinic at that time to be introducing it in gynecologic surgery. So the concept of this approach that was initially introducing caloric a surgeries to actually replace all the traditional but untested practices of what we do pay operatively for the patients with practices that research had sewn to accomplish one of the things. First of all, decrease the bodily stress response to surgery, secondly, enhance the recover of the patient and thirdly reduce surgical morbidity and some of the key components that are particularly relevant for gynecologic surgery. Because this can be tailored based on the type of surgeries that we do have included here. So the first key element is patient education is absolutely very critical to educate the patient and engagement in the recovery and said the expectations of what will happen before during and after the surgery. The second important part is reducing the fasting period so they can have souls for example until midnight liquid fluid, clear fluids until two hours before surgery. With a big deviation of the traditional packed the patient had to fast for several hours can dehydrated and in a fasting and starving um sich state. We do not give any bowel preparation even for power surgery. Even for oncological purposes. we're shooting for you eliminate pre operatively. The patients do not leave your with anti tubes very early any dress from ecological purposes for this setting. The helicopter comes out at the end of the surgery before the patient even goes to the pike. You we use a number of different non appealing medication that target different receptors so that we can minimize opioid use. They are up and moving the same night of surgery before they go home, they eat and drink right after surgery before they go home. And research has consistently shown in gynecologic surgery as well as across other surgical practices that there are very important benefits to begin by the use of the enhancer covered pathway. There is excellent pain control and it's very impressive. The amount of opioid reduction that takes place. There is early return of paul functions, significant decrease of the frequency of nosy and vomiting after surgery. There's reduction time of oral intake. Very important, very relevant for what we're trying to accomplish here, reduce hostel stay in this particular setting. It allows us to actually this is the place in the whole to home the same day, significant reduction of course. But importantly, excellent patient satisfaction and no change in the risk of the mobility and the mortality after surgery. And finally the very important they do go home the same day but they do not come back for her admission later, which means that it is successful in accomplishing what we're trying to accomplish. As the rodeo. As mentioned earlier, the robotic surgery has truly revolutionized the field of minimal invasive surgery. Briefly I know that Dr Diaz referred to these VCS uh the robotic console, the robotic at the robot. I apologized. These are 1234 the robotic arms. The instruments are introduced to the robotic comes through the abdominal s Angeles inside the patient's abdomen. The surgeon as compared to laparoscopic surgery where the surgeon operation expectation. The surgeon actually sits in the council the viewers through these um I feels and operates through the joysticks and controls the instruments inside the patient's abdomen. And there are very unique and interesting technical advantages of the robotic approach offers. And first and foremost it truly gives a very enhanced three D. Visualization um in a magnified fashion. Similar to what um it will happen during a pre surgery does give the depth perception. The laparoscopic surgery lacks. Another very important benefit is as you can see the robotic instruments articulate in the 360° of freedom. Similar to what the surgeons uh hands with you during an open surgery. And when you take these two components together, you can imagine that it offers a unique opportunity for great precision and that allows us to do high complex surgery through small incisions. And the benefits associated with robotic surgery is first shorter hospitalizations. In our case we can perform major surgeries through an outpatient setting. They're smaller decisions and that results in less pain and discomfort. There is faster recovery. The return to the normal activities quicker. There's lessons for infection. Inter operatively has been shown to reduce. There is for platt laws, transfusions and minimal scarring. Especially sometimes in oncological surgery that maybe need for future surgeries. So minimal scar is also to our benefit. The last component that is absolutely critical is not only how I care very operatively. It doesn't only matter how to do the surgery, but it is making a very big difference how we work together through a number of teams collaboratively to be able to reach our goal. And all the members of our team from our nursing, our advanced level providers are these your during surgery are administrative stuff. The surgical team is absolutely very critical that we're able to work very closely to be able to safely do major surgery and get the present safely home the same day and continue to recover at home. But the most important member of the team. Um and I would like to close by saying that the most important member of the team is the patient and the patient education that actually starts from the time of the consoles to the preoperative area during surgery. The recovery as well as after the time. The patient has gone home is absolutely critical because it is important that they know what is the expectations and how they can be actively involved in their recovery after surgery. And with that, I would like to thank you for your attention. I'm happy to answer any questions at the end of every representation. Thank you. Thank you so much elect area. That was very exciting that we can provide all those services for patients. I'm a cancer institute and I want to remind over attendees that will be taking questions at the end. So please submit those through the chat function and the same presentation so that that way we can get to all your questions at the end of all these speakers. And now it's my honor to introduce my colleague and fellow breast surgeon Dr Start Mountain er who will be talking about Miami Cancer Institute high tech, high touch approach. So high star welcome. Hi, Good evening. Thank you so much, john for inviting me to speak and thank you jane for that kind introduction. Um thank you for everyone who is joining us this evening. Um I had the opportunity to look at the list of people who had signed up to join us and a lot of the names are very familiar. Um and our local gynecologist that may have been already referring us patients. Um some people are from further away and we want to give you an introduction as to what we do within the walls of this 445,000 square foot facility if you are local. And chances are that you've driven by our facility which is on Kendall drive And it's a huge building. It's beautiful, it's very modern. Um but you may be less aware of what actually goes on within these walls and so specifically for the breast service. Um I'm going to give you an overview this evening and talk to you a little bit about what kind of programs um and resources we have to offer our patients here. And I'm going to try to advance the slide. There might be a short delay. There we go. Um So this is our breast surgical oncology team. We have six breast surgeons and many of you may be familiar with bob Der Hagopian, he still practices here and comes to the office a couple of days a week to see his own patients, but it's no longer operating. And then the rest of the surgeons are operating. Gladys Hero and Cristina Lopez Canal Jane Mendez, who you've heard from tonight. Nadia no Sarah just joined us recently and completed her fellowship training at Tampa at Moffett and then we on the end here. Um and we usually are the first members of the team that patients will encounter when they're referred for a breast cancer diagnosis. Um but we worked with several other counterparts within the building and everyone that's listed here on the right is actually under one roof here at Miami cancer Institute. And so we work very closely with medical oncology um and radiation oncology along with our breast radiologists here, the genetics team. We have psychiatry support services, reconstructive plastic surgery, fertility preservation for premenopausal patients who are interested physical therapy, acupuncture and massage therapy, just to name a few. And there's even more support services such as nutrition um and exercise classes as well. And it's very common for patients to come and see us and not only see us but have other appointments in the same day. And so oftentimes I may see a young patient diagnosed with breast cancer who has a family history of breast cancer as well. And we say, well, you know, it would be very important to get genetic testing done and so sometimes we can refer to them to the genetics team and they're seeing the same day and the blood is drawn and that process is started um Along the same lines are plastic reconstructive surgeons. We work very closely with our just down the hall from us. And so especially if patients are traveling from far away to see us, I try to get them in to see plastic surgery in the same day if possible. Um if they are interested in reconstructive surgery. Um One thing that differs between us and gynecologic oncology is that we do not operate with robots, so we're very hands on. Um But I realized during jOHN's presentation that one of the disadvantages of that is that I don't have the really cool videos that he has. Um But I will be trying to show some pretty pictures later on in the presentation. Um But we do not operate with robots that operate hand in hand with our reconstructive plastic surgeons and really are able to offer patients very nice cosmetic results um on top of offering them excellent outcomes in terms of their breast cancer diagnoses. So are breast cancer clinic is arranged in three different clinics actually. And so the breast surgical oncologist are at the top here and we deal mainly with patients who are diagnosed with breast cancer, but also those patients who have benign neo plazas that require surgical excision. So, a patient that may have, let's say atypical ductal hyperplasia or a potential phi Lloyd's tumor would still need surgical excision and would see a breast surgical oncologist. And those patients who have genetic mutations that are opting for prophylactic surgery we see as well. And we prioritize these patients. Um Within the last couple of years, we've been able to open to other clinics that are really beneficial to patients in the community that don't necessarily meet the criteria to be seeing a breast surgical oncologist but need that specialized care. And so later on this evening, we are going to be hearing from ana sandoval about our high risk breast cancer prevention clinic. And in this clinic, she sees high risk patients that are not requiring surgery. Um And then lastly are benign breast clinic. And so very often we were receiving referrals from our general gynecologists in the community to see patients who either have breast pain or breast cysts or pirates two or three benign imaging. Um And while these patients do require some reassurance at times and review of their films, oftentimes they are not surgical. And so we really saw a need to have a benign breast clinic. And so we now run this on Fridays um with Deepa Sharma, who is one of our internal medicine breast specialists along with um Dora Escobedo who is one of our nurse practitioners. And so patients really have um this resource that they do have benign breast disease, They can still be seen here at Miami Cancer Institute. Um I'd like to highlight that we also use a very high tech, high touch, multidisciplinary approach. So oftentimes while the surgeons will be the first person that the breast patient may see, we work hand in hand with radiation oncology and medical oncology. Um And it is rare for a patient to only need breast surgery when they're diagnosed with breast cancer unless it's extremely early stage zero and they undergo mastectomy. Most patients are going to require some sort of multi modality treatment. Um And so I do think it's very important that we're able to communicate with our colleagues that we are under one roof. We're all on the same electronic medical system and we also meet every single friday for a tumor board meeting where we discuss complex cases and everyone is at the table there um to discuss the case from different viewpoints, radiation oncology is there even genetics is their medical oncology and our breast radiologists as well. Um And um recently we've gotten our colleagues from Sloan Kettering to come in um quarterly and participate in these breast tumor board meetings to make sure that um what they're recommending is kind of in line with what we're recommending as well. Um I promised to show some pictures. And so I think one of the things that we have been offering patients that they really are that we should really highlight because it's not being done everywhere is the technique of nipple sparing mastectomy. And so not all patients are candidates. But there are a number of patients that either are undergoing prophylactic surgery. So they don't have breast cancer but they have a genetic mutation and they want to reduce their risk of developing breast cancer or may have small tumors that are peripherally located. Um And as long as the patient anatomically as a candidate and the cancer is not near the nipple areola complex, they may be a candidate for nipple sparing procedure. And while this is not done robotically we are able to hide the scars at the infirmary fold and offer a superb cosmetic result. Not every single patient has a result like this. But when it comes out this nice the patients are very happy and we are very happy as well. Um And so with the pandemic we actually have been sending a number of patients home the same day. Um So similar the same day hysterectomy. We've been doing some same day mastectomies once again not for everyone. Most of our patients do stay overnight one night but for the healthy young patient were able to accomplish this as an outpatient procedure. Our plastic surgeons do a nice pectoral muscle block um And patients are actually comfortable and sent home um and with a very very low readmission rate. Um And so um I think that this is one thing that is now becoming more and more popular patients are asking for it and if it's done safely can offer a really superb cosmetic result for those patients who are candidates. I'd also like to highlight radiation oncology. And so um our radiation oncology department is very special here at Miami Cancer Institute. Not only do we offer proton beam radiation therapy but more importantly we have every single modality that's available to treat a patient with radiation therapy under one roof. And we're one of the only places if not the only place in the world that has this capability. And because of that they employ this idea that the optimal the optimal modality should be given to every single patient. And so um I think they really try to tailor care to the patient and decide which is going to be the best modality to use when it comes to breast radiation. We traditionally think about whole breast radiation therapy with photons. Um That seems to work very well but there are certain patients where photons would cause unnecessary radiation to the heart and lungs, especially for a left sided cancer and someone who requires chest wall or nodal radiation. And so for those patients we are able to offer proton beam radiation therapy which is more precise and avoid scattered radiation to the heart and lungs. We can no longer say that we are the only proton beam radiation center in south florida because there are two others now but we are the largest and the most experienced. Um And so we've treated over 1200 patients with proton beam radiation therapy. And we also have three gantries here at M. C. I. Which means that there are three separate um huge facilities here within the building um that can treat with proton beam radiation daily. And the other two centers that exist. Um One in Miami and one in Palm Beach only have one gantry each. Um Additionally, we're able to offer some patients who qualify partial breast radiation therapy with either breaky therapy or protocols that employ external beam partial breast radiation that may be given over one week instead of three weeks or six weeks. And so there are a lot of different tailored options for patients when it comes to radiation therapy in breast cancer treatment. In addition systemic therapy are medical oncology colleagues, we really try to employ a holistic approach. We have art therapy here, acupuncture, in acupuncture, nutrition services, massage therapy and exercise classes. This is a photo and I don't normally, as a breast surgeon go up to the chemotherapy suite, but I had a very young patient who was 29 years old, diagnosed with breast cancer um and was engaged to get married um and within a span of a couple months we performed nipple sparing mastectomies on her and she started chemotherapy and then got married after her third session of chemotherapy here. And so you can see in the picture she's wearing a cold cap Um and that's to freeze the hair follicles on her scalp so that she wouldn't lose all of her hair and ultimately she'll probably lose 50% of it or a little bit more when it comes down to completing her chemotherapy. But for the first three sessions of chemotherapy, she hardly lost any hair. She was able to go to her wedding and look like someone who was not receiving chemotherapy and that meant the world to her. Um we had nurses that came by during this treatment to throw her a party for a bridal shower. We had the art therapist came by and brought her a bouquet of flowers. Um we had her acupuncturist come by and see if she needed anything. And so really um I was very impressed with what was going on in the chemotherapy as I know our patients are as well and we have very special patients that require very special care. And I'm so happy that we're able to offer these services. Um We see a lot of young patients here at M. C. I. For whatever reason and um I think those reasons need to be investigated further but in the meantime we do have resources for them, such as fertility preservation resources. Um And so a young patient who's pre menopausal that may not have even started her childbearing or may not be done with childbearing can be referred to uncle fertility support services. In addition we have a new sexual health clinic. So many of the treatments whether it be chemotherapy or endocrine therapy really affect women in terms of their sexual health. Um And there was such a need for this and so I'm so happy that this was just opened for female patients. Um And we also have a separate male sexual health clinic as well. Um And lastly we offer survivorship. And so once a patient has completed treatment, we refer them to our survivorship clinic, in which case they are given a summary of all of the treatment they received um what their treatment plan is going forward and any side effects that are currently being experienced during treatment or gone over to see if we can help with those side effects. So it's a really nice summary that's given to patients at the end of their treatment. Lastly, I would like to talk a little bit about research and innovation, john already touched on the important aspects of the M. S. K. C. C. Alliance that we have with Sloan Kettering through that we are actually able to open clinical trials. Um and there are a couple of interesting ones that are in the pipeline that I'm working on with our breast surgical oncology colleagues. Excellent catering to bring here both of those trials aim at decreasing the morbidity of treatment of breast cancer. And so we're looking at Seeing who can we safely omit axillary lymph node dissection on a number of years ago now. A important seminal study called Z11 came out showing that not all women that had um lymph node involvement required a complete axillary lymph node dissection if they were undergoing a lumpectomy followed by radiation therapy. And we're now seeing if we can expand that criteria to other women as well that would traditionally require axillary dissection. Um Ana Sandoval is going to tell us more about her breast cancer prevention clinic but she's running a trial in which we analyze how patients make decisions about um undergoing chemo prevention or preventative care to decrease the risk of breast cancer. And our medical oncologists have a number of trials that they're able to offer patients that are living with metastatic breast cancer specifically through the Sloan Kettering alliance or radiation oncologists have several trials where they're able to radiate patients with certain metastases. And there is a very interesting trial going on right now analyzing protons versus photons for patients who have internal memory nodal involvement um looking at cardiac endpoints and so I think that we are just starting off, this cancer center is only about five years old and um we've done a lot of work in those first five years and so um I'm looking forward to seeing what the next five years old. I would like to thank everyone for attending. Um One of the criticisms that I've heard for referring patients to a very large cancer institute like M. C. I. Is that sometimes it's hard to get your patients in and that should never be an issue if you have a patient that has been diagnosed with breast cancer and needs to be seen, you should be able to get them an appointment within 48 hours. Are scheduling numbers at the bottom of the page. But I also listed all of our email addresses because I'm happy to give anyone my cell phone or email address just to make sure that you have no issue getting your patients in to be seen. Um in a timely manner. Um Thank you and I will hand it off now to dr Sandoval to tell us more about the high risk breast cancer prevention clinic. Thank you star for associate thorough review of the services that we can offer for our breast cancer patients and beyond. So now it is my honor to introduce again dr ana Sandoval. And ANna will be talking to us about breast cancer prevention. Thank you. Anna welcome. Hi everyone. I'm Ana Sandoval. I'm a breast medical oncology that Miami cancer institute. But I'm also a I see patients with breast cancer but I also see patients that are high risk of developing breast cancer in our breast cancer prevention clinic. So this is an outline of my talk. I'm gonna talk uh who do we see in our breast cancer prevention? Then I'll go over uh of some of the things that we do during the visit for our patients. So we need to know first what are the risk factors. We calculate their risk using different mathematical models. Then we based on this, we decide who should get mris. And then we discussed chemo prevention and we can also assess who needs genetic testing. Yeah. So who do we see when I see patients that have a high risk of developing breast cancer and this can be due uh two different reasons. Sometimes they have genetic mutations that increase their risk of breast cancer. They can also have a strong family history of breast cancer with not identifiable mutation. Uh We if patients have a lifetime risk over 20% there are also candidates for to be seen in the breast cancer prevention clinic. And we calculate this with the tire acoustic model, patients that have history of mental cell radiation or patients that have underlying high risk breast conditions like lobular carcinoma in side or a typical hyperplasia. What are some of the risk factors? I mentioned, Some of them age, uh genetic mutation, family history, radiation. This prior breast biopsies. But also it's important to know that patient with dense breasts are at risk of developing breast cancer. This is usually shown in the mammograms. Now it's part of the report patients that are Ashkenazi jewish are also at risk of developing breast cancer. Hormonal factors like having your first nancy between before age 12 or late menopause after 55 Also having kids after 30 or not having kids is a risk factor. There are some modifiable factors and these are the ones that we have to counsel our patients and educate them. Uh Some of them are obesity, alcohol use and hormone replacement therapy for over five years. So using all these factors, they have many mathematical models developed. The ones that are routinely using the clinic is the girl and the tire accusing the Gail model is the most comprehensive model. It's a very long list of questions that we ask and it can take some time. It's important to know that it we ask about President City and we asked an extended family history. So not only first but also 2nd and 3rd degree relatives. We asked the age of the family that had breast cancer, they had bilateral breast cancer. And if there was over in our male breast cancer in their family. This model tends to overestimate the risk in patients with a typical hyperplasia lCS or patients with the expressed. Usually we get a 10 year risk or the lifetime risk. And the lifetime risk is the one that we use the most to decide which patients would benefit for mris. On top of the regular mammograms and ultrasounds. Many reports also including in our institution now incorporating your mammogram, what is your entire qc? Decrease your lifetime risk. So, it's easy for clinicians to know which patients can be referred to a breast cancer prevention clinic. The game model is much shorter. It's just a few questions. It takes like a minute and I use it to determine which patients will benefit for chemo prevention. Why? Because this was the model. Using the majority of the chemo prevention trials, they use a five year risk of over 1.67% to uh for the patient to be eligible to participate in the trial. So who should get breast mris. According to the american cancer Society, patients that have some genetic mutations that put them at higher risk of breast cancer should get breast mris routinely on top of the regular mammogram and ultrasound. It's not it's not. Instead is both of them. Usually we stagger them. So the mammogram and ultrasound and then six months after we have them. All right, so we have some sort of image every six months As mentioned patients that have a lifetime risk of developing breast cancer of over 20% and patients that have prior breast radiation Chemo prevention. Okay. This is a summary of the chemo prevention trials. As you can see, there have been many trials. The N. S. A. B. P. P. One is the larger one. It included 13,000 patients. Over 13,000 patients and patients were randomized to either placebo or chemo prevention. The patients were allowed to participate if they met different criteria that they considered high risk. And one of the criteria was a gale of over the five year risk of over 1.67 as you can see all of them show that chemo prevention works. There is a risk ratio of .69 for tamoxifen for relax. Even in this meta analysis was .44 and for a romantic inhibitors was 0.45. Uh It's important to know that there was a study, the star trial that compared tamoxifen to relaxation and it seemed that tamoxifen was superior. What about safety relax? If in an tamoxifen can be good for your bones and they have shown to decrease the risk of fractures. So if you have a patient that is high risk and have osteoporosis. Probably these are the medications that we can consider prescribing them tamoxifen and raloxifene were associated with an increased risk of from metabolic events compared to placebo. And this is one of the main reasons why patients are reluctant to take these medications. Tamoxifen seems to have more adverse events that relaxation. Tamoxifen was also associated with higher risk of indo mutual cancer and cataracts. And all these medications, tamoxifen, raloxifene and a romantic inhibitors were not associated in these particular meta analysis of increased risk of coronary heart disease or strokes. Symptomatic events. Very among uh the draft. And this is also another reason why patients will be reluctant to take these medications or will they stop the medications. So what do the guidelines say? Uh There was an athlete in 2019 of AsCO and U. S. D. S. D. F. But mainly the recommendation is that clinicians should offer prescribing these medications to women that I had risk and are over 35 years. This is the cut up that for patients that were included in the trials and patients should have completed childbearing. Right? Because you get genetic testing. So we know that Ashkenazi jewish that at higher risk of developing breast cancer. So they should be offered genetic testing patients that have a probability of mutation of uh B. R. C. A. One or two of over 5%. And you can calculate with models like the terra Qc patients that have a family history of breast cancer and also somebody in their family of the or the same person uh that was diagnosed with breast cancer If they had a variant pancreatic or prostate cancer and patients that I have a first or second degree family member with history of breast cancer and that that person should have received genetic testing. And this is a very long list. But these are the guidelines for patients that have breast cancer. So if the patient had a family history, family member who had breast cancer and met criteria did not get genetic testing, that patient can get a genetic testing. So what do we offer in the breast cancer prevention clinic? As you can see we individually in the individualized breast cancer help plans for each patient. We do a risk assessment if pertinent to each patient. We decided they need enhanced monitoring with breast imaging and recent exam we discussed lifestyle modifications is extremely important to talk about diet and exercise because as you can see obesity is one of the modifiable risk factors for this patient. We discuss about chemo prevention and we discuss if they are eligible about surgery and then refer them to our colleagues that are here in our meeting. If they have a. B. R. C. A. One and B. R. C. A. Two, they surely will see surgery and G. Y. O. Um we also offer them genetic referrals if needed. And we have a great supportive team that I have mentioned already several times throughout this meeting of nutrition psychology psychiatry, exercise physiology among others. Finally for patients that have high risk leashes, not for all high risk patients but for patients that have a typical hyperplasia or lobular carcinoma. In side of we currently have a clinical trial non therapeutic that is looking at a tool to help patients make the decision regarding taking or not chemo prevention. So if patients get access to this tool they can estimate the risk graphically. They can. They also have to answer questions regarding their preference about taking medications and about the risk of breast cancer. And then they have a lot of educational materials. When they complete this we get an action plan and on the six month visit we discussed to the patient with the patient and then the patient decides if they want or not to take him a prevention. Thank you. Thank you ana for social superb description of the services we offer the breast cancer prevention clinic and with that I'd like to thank all our speakers for their superb talks. So now it's time for questions and I have the first one and it's for you dr Kellogg era. Somebody would like to know when our patients new not new good candidates for the same day. He's corrected me not what candidates. That's a very um that's a very good question of course. Um I will speak in general terms but um if the patient is clear for surgery um if they have some comorbidities that can be controlled before the teachers. So that includes even older patients, patients who may have like even some cardiac disease or um arrhythmias, diabetes, all these things that we can control and they can go home the same day. So AIDS is not a limitation. Um comorbidities is not a limitation as long as they can be exacerbated away have older vital signs appropriately manage before they go home. If they have, if they're kind of for robotic surgery, for example, if they have a surgical history that allows for the robotic surgery, that doesn't mean that they cannot have had surgeries in the past. But if we think that we can safely do robotic surgery despite the surgical history, that would be another kind of foreign outpacing the hysterectomy. And then um it really depends on what happens during surgery. If everything goes well, there are no unforeseen into operative findings. If everything goes as planned, then they can go home the same day. So for the most part, as long as we can safely do a robotic surgery and the surgery goes well. And there are nothing that comes up into operatively or post operatively in terms of the comorbidities and how their management or particularly they can hope can can go home the same day. I will say the vast majority of the patients that but in the clinic we feel that there are reasonable countries when we counsel them are able to go home the same day. Very rarely something will come up that will make them requiring over United States. So this is very far and few in between. Thank you so much. Next question I have is a for john DEA, somebody would like to know when you would treat somebody with the high pack. So what would be some medications And if so, how can they refer a patient for the high peak therapy? That's a great question. So right now, the Ntc in Guilin recommendations are in those women who have ovarian cancer and are being treated with neo adjuvant chemotherapy. In other words, for whatever reason, we felt they weren't a good initial surgical candidate after they received 3 to 4 cycles of chemotherapy there re evaluated and at that time they're considered good candidates for interval sod reduction. That's where we would use hypothermic interpretive commentary in the up front setting in the recurrent setting, It's less clear. But those patients who have a platinum free interval of greater than six months uh and are considered to be good candidates for a secondary saturday procedure. We also offer high pick in that setting for non gynecologic cancers. It depends on the disease status. So the low grade of penicillin cancers, sumac soma, uh pelvic mesothelioma and select gastric and colon cancers. We perform those surges in collaboration with our surgical in college and are colorectal surgeons. But I'm always happy to see a consultation. It always throws my team off a little bit when I have male patients in the waiting room who are coming to see me for who I pick up a little bit confused by that. Um But we have a very proactive program that's supported by institution and so happy to see any patient you feel may be a candidate for high peck. Thank you john. Uh The next question is for dr Mautner and there's some interest is in learning what might be some contraindications to the nipple sparing mastectomy what patients might be not good candidates for that procedure. So when we see patients that are interested in nipple sparing mastectomy, there are two different factors that we look at. One is from the oncological perspective, what would make them not a candidate? And the other is from the plastic surgeon's perspective, what could make them not a candidate. Um And so from the oncological perspective, obviously if there's nipple areola complex involvement, that is a strong contra indication to nipple sparing mastectomy. Um In general we say that if there's calcifications or a mass within a centimeter of the nipple areola complex, that also is a contra indication to nipple sparing mastectomy um we can use MRI to kind of differentiate if there's any enhancement leading up to the nipple, but that's not always accurate. Um And so I always tell patients that if we're going to attempt nipple sparing mastectomy, we're going to take a nipple margin of tissue just beneath the nipple areola complex. And if that were to come back positive for malignant cells, then I recommend that we go back to the operating room at a later date to remove the nipple areola complex. That is rare but it can happen. Um And then from a plastic surgeon's perspective, patients anatomically may not be a good candidate for nipple sparing mastectomy depending on where their nipple is located. Um And so if the nipple points downward beneath the infirmary crease, that's considered to sis and those patients cosmetically just don't come out as well because the nipple won't be in the right position when we do a nipple sparing mastectomy. And so there are some ways around that if this is a prophylactic case so that you have all the time in the world to plan this out and it's truly elective. You can stage the procedure and have the plastic surgeon do a master pixie to lift the nipples and kind of do a reduction put the nipples in the correct position prior to doing the nipple sparing mastectomy. They usually do that 6 to 8 weeks before the final surgery. And so that would be considered a staged procedure. Um But I would say the ideal nipple sparing candidate is someone who is relatively small breasted has noto sis. Um And either does not have breast cancer and is doing this preventatively or has a small cancer that's far away from the nipple. Um We are expanding criteria more and more as we do more and more of these cases and see what can safely be done. Um The other criteria is I really don't like to do these in smokers because they have impaired blood flow to the skin and nipple due to nicotine um and vessel constriction. And so you have a higher risk of complications in terms of skin and nipple necrosis and patients who are heavy smokers. Um And so I think that if a patient is interested they have to meet criteria not only from the surgical oncologist but from the plastic surgeon as well. Thank you Start. That's you know that's great to create that awareness again. It's great for the cosmetic campo but we have to keep all these other factors into consideration. Next question I have is for dr Sandoval there's a question pertaining to aromatase inhibitors. Somebody would like to know if it's seven days versus five days after five years of aromatase inhibitors. They don't specify this in the chemo prevention setting or is it in the cancer setting. So if you can address both please. So for chemo prevention all the trials were done for five years. There was a small italian study that used a lower dose of tamoxifen or aromatase inhibitors. The regular dose of tamoxifen is 20 mg. They use a five mg dose that we don't have in the U. S. And they use it for three years. And there was also decreasing the risk of developing breast cancer. This is different for the indication for patients that have breast cancer. The patients that have breast cancer should at least get five years of endocrine therapy either tamoxifen and aromatase inhibitors. And some patients benefit from extended endocrine therapy up to 10 years. So the more than 10 years there is really no data and there are now there have been developed different essays genomic essays that we use. For example initially we use some of them to decide about chemotherapy. Now some of them, one is called the breast cancer index can help us decide which patients will benefit from extended endocrine therapy if they have breast cancer. Thank you. So with that I'd like to thank all the attendance for spending part of your evening with us. It's been great to share this one with you and at least make you aware of all the things we can offer. High tech, high touch at our Miami Cancer Institute all under one roof. So looking forward to working with you and answer any questions that you might have. And thank you for christophe latest putting this program together and inviting all of us and thanks to all my colleagues for their wonderful presentations. So with that all had a great evening and thank you for your time. Thank you bye bye.
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