S1E10 | Lung cancer: Advances in screening, treatment saving lives
S1E10 | Lung cancer: Advances in screening, treatment saving lives
Bruce Gershenhorn, DOLung Cancer Program Director, Cancer Treatment Centers of America
Pat Basu: Hi, I'm Dr. Pat Basu, the President and CEO of Cancer Treatment Centers of America, and the host of Focus on Cancer. I'm very excited about today's show where we are going to cover everything from screening to treatment, to the future directions of lung cancer, very timely to given this is lung cancer awareness month. My special guest on the show today is a world renowned expert in lung cancer Dr. Bruce Gershenhorn. Dr. Gershenhorn is the Director of the Lung Cancer Program at Cancer Treatment Centers of America. Dr. Gershenhorn, thanks for being here. Welcome to the show.
Dr. Gershenhorn: Thank you, Pat. It's an honor and a pleasure to be here, and I'm excited to give you all my insights into how we go through lung cancer from diagnosis and screening all the way through treatment options.
Pat Basu: Well, Dr. Gershenhorn, whenever I have physicians on the show, it's easy to see the end result. You're a leader in cancer. You lead the Lung Program at CTCA, but oftentimes at the beginning, I love to go back in time a little bit and get a quick understanding of why you chose to become a physician and in particular, to lead this battle against cancer and take care of our beloved cancer patients.
Dr. Gershenhorn: Ever since I was young, I would say my, even my high school years and in early into my college years, I really always felt a strong desire to help people and help people not through mild illnesses, but help people when they really need it, when they're really sick. And I've had experiences where I've had oncologists and family friends who I shadowed when I was in high school, just to get an idea of what it would be like to be a doctor, or what would it be like to be a doctor specifically for cancer patients, and I was drawn to it. I was drawn to the desire to help people at times when they really need the help.
Pat Basu: Well, you certainly chose well as somebody who loves helping people and advancing clinical science to battle cancer. We're so glad and grateful that you did. Very few people in the world as equipped to talk about the important topic that we're here to discuss today, this is one that I know is near and dear to us. It's an important topic to so many of our audience out there, because sadly as you and I both know and many of our audience members know is one cancer is highly prevalent and one of the most fatal types of cancers out there. In fact, it is the second most common non skin cancer type. And number one, in terms of death. In fact, more people die of lung cancer every year than breast colon, pancreatic and several others combined. So really an important show for our listeners. Let's start with something that is critical to the slowing down or the hopefully at someday, the stoppage of deaths from lung cancer. That's the topic of screening. Dr. Gershenhorn, why is screening for lung cancer so important?
Dr. Gershenhorn: The point of a screening test is to pick up a problem or a potential problem before it becomes a major problem. In lung cancer, we really want to pick up a small lung nodule when it's stuck in the lung and it has not spread. In order to do that, we've got to do specific testing, specifically a CAT scan on the lung, and it will help us find these nodules when they're very small before any spreading might occur. All cancers start at the stage one, which is when they're isolated in the lung, and they'll spread over time if left alone through to a stage four, which is when the cancer spreads to other areas of the body. So in order to catch these things early at an early stage when the survival rates will be much higher and the chances of beating the cancer is much higher, we've got to do screening tests. And for lung cancer, the screening test is a CAT scan. Just like in breast cancer, we're very familiar with mammographies and in colon cancer, we're very familiar with colonoscopies. In lung cancer, the CAT scan is the key, and it's the key to finding these things when they're small, when they're asymptomatic, and before they spread, which will result in a much higher likelihood of getting rid of them and curing them ideally with surgery or radiation.
Pat Basu: You mentioned that the metaphor mammography to breast cancer, colonoscopy to colon cancer, we do have this really terrific test, the low dose CT to screen for lung cancer. Tell our audience a little bit more about that. How does that work? What should they expect with the CT scan of the lungs?
Dr. Gershenhorn: The CT scan is like a large donut, and basically it's a painless procedure. It's very quick, it's very readily available and you lay down and you go right into the machine. Now, it's an open machine as opposed to an MRI where people have trouble sometimes with claustrophobia when it's closed. It's a very quick painless test, it's available on almost all centers throughout the United States, and it's invaluable with looking into the lungs. Now, there was a study in 2011 published in the New England Journal of Medicine that compare doing these CTs or CAT scans to a chest x- ray. They looked at over 50,000 patients and they found that the CT scan, as opposed to a chest x- ray is extremely valuable at finding these small nodules in the long, sometimes as small as a blueberry or a grape. And when you find it early like that with CT scans, it allows us to treat them before they spread. The other comment I wanted to make is that in the lung, it's like a gigantic sponge and things can grow fairly large inside that sponge before you even know it. So lung cancers can get from say a blueberry to an apple or an orange to maybe even a grapefruit with minimal symptoms. No pain, maybe a mild cough, but it's very easy for a cancer to grow in the long without you knowing it. And that's the value of doing the CT scan as a screen, you're doing it before the symptom develops while the cancer is at a much, much smaller size, which allows it to be much easier to treat.
Pat Basu: Absolutely. It's a terrific test. As you mentioned, it's fast. We're talking about the scan being done in 30 seconds or less, we're talking about it being non- invasive, the results are available very, very quickly, really a remarkable cross- sectional image that can be reformatted to even a 3D view so that the patient can see exactly what we're talking about. Another advantage is it gives us as physicians a really good precise location of where a potential lung cancer might be. We can talk about whether it's involving any of the airways in our lungs, what we might refer to as bronchi or the blood vessels in our lungs or the edges of the lungs that we can quickly determine some hypotheses around what treatment might look like and what it might entail. So as you mentioned, it's a terrific test, a wonderful screening test, but it's actually not for everyone, not traditional. Tell us, what are some basic guidelines of the type of folks who should consider getting a lung cancer screening?
Dr. Gershenhorn: Lung cancer is predominantly a disease that happens in smokers or ex smokers. Now, it can happen to people who never smoked, but the vast majority of people who succumb and suffer from lung cancer are smokers. The criteria that was established in that New England Journal study that I referenced earlier was two main factors. One is age. Anyone above age 55 and up to about 80 were candidates for the screen, and the second one was the smoking status. They had to smoke more than 30 pack years. A pack year is defined by the number of packs per day times, the number of years smoked. For example, if someone smoked a pack a day for 30 years, that's 30 pack years. If they smoke two packs a day for 30 years, that would be 60 pack years. The criteria were established in that study was you had to have smoked for more than 30 pack years, and if you quit, you had to have quit less than 15 years ago. So again, the two main categories are age and smoking status. This is different from mammography and colonoscopies, where say, for example, in mammography, all women are candidates above a certain age and colonoscopy, all men and women are candidates above a certain age. With CT screens for lung cancer, we're more pinpoint and precise to the smoking population.
Pat Basu: Thank you for that. In fact, there's some very recent research I think just a month or two ago that the Journal of the American College of Radiology had published some reports around various populations that actually might be at even increased need to get screened lower than the 30 pack year threshold, African- Americans in particular. And we talk often about health disparities, the idea that various patient populations might have worse health outcomes or a greater risk of certain diseases. This article did an excellent job of pointing out the idea that even though we think of 30 pack years as Dr. Gershenhorn described as that threshold upon which everyone should get screamed, that in the African- American population in particular, that number may in fact indeed be 20 pack years to beginning to get screened. So along those lines, the US Preventative Services Task Force often referred to as the USPSTF, a little bit of a mouthful, is the federal body that releases a lot of the screening guidelines. So when people hear about when they should get mammography done or colonoscopy or flu shot, this is the body that does so. They've expanded their screening guidelines, and that's designed to double the number of at- risk smokers to get screened. Tell us a little bit about their thinking behind that and the impact that this likely will have.
Dr. Gershenhorn: Very recently, the number, specifically the age was dropped from 50, so from 55 down to 50, and the number of pack years smoked was dropped from 30 pack years to 20 pack years. And I think this is going to help us. It's going to help us find more potential candidates for screen because we're expanding the population, and it's going to allow us to find more of these early stage lung cancers, which again, give us the opportunity to help these patients through a cure.
Pat Basu: Terrific. Right now, I think that's outstanding and I think that's very much going to help but right now there's just too many people Dr. Gershenhorn that are not getting screening even when they do meet the criteria. Huge problem, and just a huge opportunity for us to catch these earlier. Do you have any thoughts or maybe some statistics around the number of patients who should be getting screened in the current guidelines that are not currently?
Dr. Gershenhorn: Yeah, I know this is a major issue because when the data came out in 2011, the thought was this was going to be practice changing and community doctors and lots of patients were going to undergo these screens. And actually in reality over the last 10 years, it just really hasn't picked up a lot of steam. There's a lot of thought as to why ideas hypotheses. One hypothesis, which I'm not totally on board with was that the information isn't out there, there's not enough education amongst community physicians and the patients at large, or that there's just not as much access as there needs to be to the CT scans. I can tell you, in my practice, we implemented a caregiver screening program where all the patients that I have with lung cancer that come with caregivers, I approached a caregiver about their smoking status and the role may be for going through a screen for them. And it's surprising that it's harder to get patients, and I'm not sure exactly why. I don't know if there's a sense, there may be a sense of guilt for decision made. There may be a sense of fear, there may be a sense of, I don't want to go through the screen. I don't want to find out what's happening in my lungs because of maybe a bad decision I made in my earlier days, but it's very interesting that they don't necessarily have that same vigor and excitement about lung scan as maybe someone might about a screening mammography. And I think there's a lot more research that needs to be done to understand why after 10 years, we're still not seeing a lot of patients undergoing screen. And one of the statistics states that maybe 10% or less of the potential candidates for lung screens are actually getting those scans done. And I can tell you, in my practice, I have patients who have undergone lung screens in their local communities. They found a small lung nodule, and we've treated it here. And it makes me really happy to see that because I know if they didn't have that scan, that spot would have grown bigger and bigger and spread. And then it would have gotten to the situation where it probably would have metastasized, and it would be much more difficult to treat.
Pat Basu: I think, again, not mutually exclusive, breast cancer is absolutely something that everybody knows, but I feel like in the month of October and other months, there is just so much out there in terms of the pink ribbons. Some of those, I for one would like to see even more continued awareness about the importance of lung cancer and in particular, the importance of getting screened. That said, we're going to talk about treatment in a moment, and I know there's a lot of exciting things to talk about in lung cancer treatment. Let's just talk briefly as a bridge between screening and treatment about diagnosis. Can you just lay out for our audience a good way to think about the different types of lung cancer? Obviously, not all lung cancers are the same, there's various categorizations and histology. Can you walk us through a framework of the different diagnosis?
Dr. Gershenhorn: Sure. It used to be actually a lot more straightforward. It was either small cell or non- small cell. You had two categories, and they were treated actually fairly similarly. Over the last 10 to 15 years, we've learned a lot more about both types of cancers and specifically a lot more about the non- small cell lung cancers. And we've subcategories them by mutations or genomic alterations we call them, and by immune marker status. These specific features in the cancer help guide our treatment recommendations. So it's not, all non- small cell lung cancer is treated the same and all small cell lung cancer is treated the same. There's a lot more we do with the cancer biopsy now that we never did before, and there's a lot more testing that's being done before the treatment recommendations are even started.
Pat Basu: I often say that when we were training Dr. Gershenhorn, there might've been a handful of cancer types or there might've been maybe a couple of major types of lung cancers. You mentioned small versus non- small cell, or maybe three or four if you actually get to the actual cell type. But as I often say now, that's expanded to hundreds or maybe even thousands based on the underlying genomic characterizations that we have of the tumor. On a previous show, we did a deeper dive into genomic medicine and precision medicine. And the lung cancer is clearly one of those areas where it's expanded sort of the number of different types of cancers, I guess, if you will to think about it, but at the same time, it leads to tremendous opportunities and treatment because now we can be much more targeted in what we're going after. I know we've made rapid advances in treatment, and it's having a real impact. Lung cancer death rates are coming down faster than incidence rates. Talk to us a little bit about some of the advances in lung cancer treatment and some of the things that might be on the rise.
Dr. Gershenhorn: One thing I'd like to do is, and this is a room where I see my patients every day. They sit here and I sit right here and I use my dry erase board to lay this out for patients. Now, what I'll usually do is I'll explain the three different categories of how we treat. And this is typically when lung cancer has spread when it's not an option to do surgery anymore. And the three categories are, number one is chemo, number two is target drugs. And again, I'm going to explain a little bit about all three subtypes. And number three is immune drugs. Chemo is the category 10 years ago that we were only talking with then. We had a certain number of drugs, platinum- based treatments and maybe a second line treatment and that was it. Now, before we even start the treatment, we look into targeted options and we look into immune marker options. As far as targeted options, there's a test called genomic sequencing or next genome sequencing. This test I likened to understanding the engine, the driver of the cancer. So it's a fancy test that takes about a week to two weeks to run, and it tells us all the mutations or engines that formed in that lung cell that turned it into a lung cancer cell. And we're very good at understanding and finding these engines. The key is, do we have a target that's already available as a pill to shut down one of those engines? Now, in lung cancer, there's at least a different targets now where we have defined drugs that are pills, that are not chemo, not immune treatments, and they dramatically changed the landscape of how we treat the cancer, the overall prognosis, and the side effects from the treatment. So the most common one say, for example is EGFR. EGFR is a mutation in the cancer or an engine that we have multiple different pills now that can target. And sometimes these drugs work for years before we even consider other categories. So we'll always this test, or a variation of this test at the beginning to see if we can be in this targeted category when we start treatment. For the immune category, there's a test called PD- L1. PD- L1 is an immune marker that gives us a likelihood of immune treatments being active against the cancer. And when I say immune treatments, these are usually IV drugs that either are given alone or are given with chemo, that stimulate your immune system, that motivate, excite your immune system to try to find the cancer cells and kill the cancer cells. Now, this has been a major advance in the frontier on how to treat cancer, because what we're doing is we're exploiting your body's natural defense. And we only think of our immune system as, well, we can fight the common call. We can fight other pneumonia, other infections because our immune system kills the infection off. The problem with cancer is that since it's not a foreign product going into your body, it's actually part of your normal cells. It just gets tweaked in some unusual way, the immune system doesn't see the cancers. So it leaves the cells alone. Recently drugs have been developed that educate your immune system into seeing what's different about the cancer and how to target it. And the drugs when they work, dramatically change the landscape of how the cancer behaves in the body and how your body responds and can sometimes give us long- term control. These are more toxins almost, little toxins that kill cancer cells directly. These are almost like smart bombs to go after cancer cells based on the genomic engines that are active. And again, everyone's genomic engine is different, so we got to look to see what specific targets we could go after, and then this is an immune marker to give us an idea of how well on a new treatment would work. So these tests are done frequently before we even start the treatment, once we know someone has say a non- small cell lung cancer. The results of these tests define the way we treat the cancer.
Pat Basu: Fantastic. Really, really liked the way you clearly laid that out for our listeners. I think all too often in medicine, communicating complex subjects to patients especially after they've just gotten such a horrifying diagnosis can really be a breakdown. So you laying out chemotherapy, targeted therapy and immunotherapy in such clean fashion I think is tremendous. And then the underlying analogies which I agree with, whether it's the engine or the smart bomb therapy, if you will, for the targeted therapies and then the revving your own immune system to catch and stop the cancer. I sometimes say it's like handing out mugshots or giving some other flag to your place for us to say, " Hey, this is a domestic terrorist threat as opposed to a foreign terrorist threat," so that they can recognize it's your own body's cancer cells doing so. And the question that we often get asked by patients, is who should go through some of the testing, and when should they do that? Can you talk about when and which patients should get genomic testing or things to see if they're a candidate for targeted therapy or immunotherapy?
Dr. Gershenhorn: Yeah. Typically, it's in the non- small cell lung cancers as opposed to the small cell lung cancers, and more specifically amongst the non- small cell lung cancers, it's the adenocarcinoma. It's the name of this cell type of non- small cell lung cancer that becomes cancerous. The adenocarcinomas and even more specifically, the non- smokers who get adenocarcinoma have the highest likelihood of having one of these alterations that we could target.
Pat Basu: Fantastic. Very, very helpful. And I know patients have asked us about that before. Speaking of which, you and I, we get excited about the innovation, we are passionate about the science, but we do this because we care deeply about every one of our patients and really the battle against cancer. And hopefully eventually defeating this horrible disease. What you've just covered, I think is just a dramatic advance in the approach, but we're seeing some of these actual impacts in our patients. Do you mind just sharing a story of a patient or two that you've encountered where they've benefited from some of these therapies?
Dr. Gershenhorn: Yeah. I have multiple patients that come to mind, but very specifically a few. It dates back to the early days when immune therapies were just becoming in vogue in treatment approaches for lung cancer. One case was a woman who was in her 60s who had an adenocarcinoma of the lung, she was through a few different types of chemo, and it just wasn't working well enough, and a mass was growing out of her neck from the cancer, and it was starting to cause her pain and discomfort. This was back in 2016 and it was right when the first immune drug got approved for the non- small cell lung cancer. We treated her with it and very quickly the mass shrunk. The reason why this was so impactful for me is first of all, it was the early days of using immune treatments. What this woman did was she over time, while probably six, nine months into immune treatments, she started taking pictures of things she was doing, that she'd bring to me each time she'd come for a visit almost as a thanks for life that she's allowed to live, that she may have not been able to live if the drugs weren't working. What she did was she would bring me just a picture of things she did. Walking her dog, riding her bike in the park, a little vacation, maybe a bucket list item like Stonehenge, and even things simple, going to the movies. This is so powerful to me because this is life. Life is doing the general things, the things that we all take for granted every day, because we're not faced with a life- threatening illness, but when you're faced with something as serious as an advanced cancer, and you think your days are very limited, and all of a sudden a treatment works that was really brand new and you go back to living life, just doing things that, again, we all take for granted. Hanging out with our family, walking the dog. It becomes almost a daily frustration walking the dog, but not to someone who's staring death in the face that all of a sudden got a new lease on life. So her pictures really, it's not some wedding that she got to experience. It's day to day life that she gets to live because her treatments worked. And immune drugs, these pictures are from 2016, 2017 and I see her every three months now. She doesn't bring me as much pictures as she used to, but she's doing normal life, which I love. That makes me so happy. That fulfills me as an oncologist.
Pat Basu: I love that. I am so glad you shared that because all too often, it's human nature to take health for granted. It's human nature to take life for granted until something as horrible as this stops us in our tracks. And I know many of us and our listeners can relate to that story, but I'm glad that you shared that story and showed those pictures because that is what it's all about. You can talk about the drugs and the science and the numbers, but it's all about the patient and it is all about those moments in life. That is why we're here. That is why we do these things. It's not just about adding years to life, but adding life to years and so I am really, really glad that you shared that. Very, very powerful.
Dr. Gershenhorn: Well, another patient, and again, this was a small cell lung cancer patient, which is a very deadly disease, especially when the first or second attempts at chemo don't work. This was a gentleman who had cancer in his brain, cancer in his liver cancer in his lungs, and the chemo wasn't working. And him also, we started immune treatments. A similar thing happened to him. Again, this doesn't happen for everyone, unfortunately, but there are patients who really, really, really tremendously benefit. And what happened with him was over time, started getting better and better. His wife would always come for every visit and she would bring me soaps that she made. It was right at a time where my wife was also getting at soaping. So they became friends, my wife and his wife. She came to our house. And then eventually he came to our house and he had dinner with my kids. And they share life experiences. You share with people that should... And I know as a doctor, the situation that they're in and what they're facing, and all of a sudden you turn it around. Again, I wish this happened more often, but it does happen in real life. He sat at the dinner table with my wife, my kids soaping. It's just, these are things that five years ago, no chance. No chance these people would have survived, and now they do. Immune therapies do something very interesting to cancer that no other treatment does. Once you harness the power of the immune system to get control over these diseases, frequently it stays that way. And years can go by and they have excellent control. Some people are off treatment like the gentlemen with small cell, he's off treatment because he had toxicities and he's off all treatment. Now, the woman, the first story I told you, she's still getting the drug four or five years later, but they get long- term survivals and that's huge.
Pat Basu: It really is. I'm glad you shared just two of those patients' stories out of so many because it brings it to life. It gives us the reality and the optimism and the hope and it reminds us why we fight this battle every single day and why we're so grateful to leaders like you that are pushing the envelope and pioneering the fight against, in this particular case, lung cancer, but the cancer as a whole. Along those lines, no matter how much we've done, there's always more left to do. And you've just described tremendous advances in screening and diagnosis and treatments. You've shared a couple of these stories, but we know that there's still a lot left to do. As I said at the top of the show, lung cancer remains the second most common occurrence and the leading cause of death really dwarfing many of the other large cancer types that people are aware of. So we have to do more. Share with us, what are some of the concerns? What are some of the big challenges ahead in our battle against lung cancer?
Dr. Gershenhorn: I'm going to share two very unique, very hopeful and exciting stories. But in reality, like you said, the majority of patients, if you don't catch it early, and it's at stage four or metastatic cancer, the immune drugs, the target drugs, the chemo drugs don't work well enough. And people still succumb to the illness frequently. So we've got to get better at coming up with unique targets. We've got to get better at understanding when the immune drugs don't work, why don't they work? What about the person's immune system in someone you get a dramatic response, and in someone else, you get no response? Now, the marker, that PD- L1 marker I discussed earlier is a way to get an idea, but it's nowhere near definitive. So we need to come up with... I think the next frontier is again, more immune options, better immune targeted drugs that harness your body's natural defense for health. But I see us moving slowly away. Right now we're still using a lot of chemo, but I see us moving slowly away from the cytotoxic, which is a classic chemo drug and more toward unique targeted drugs and more toward immune combinations. Now, this requires a lot of research and clinical trials. A lot of the studies that we're doing here at CTCA are frequently focused on the genomics of cancer. So understanding what engines are active, how to shut down those engines. Sometimes we'll treat a lung cancer like we would have treated a breast cancer or a lung cancer like we would have treated a melanoma because they have a similar targeted engine that we know is active in a different cancer that we treat in lung cancer. So there's a lot we still need to do to better understand how to treat these cancers when they don't respond to our initial treatments.
Pat Basu: Couldn't agree with you more. I think it represents both a challenge and an opportunity and there's so much. There's so much in the prevention arena of lung cancer, as successful as the United States has been at least based in decreasing smoking in the prevention side. There are still plenty of smokers out there. In fact, especially more women outside the United States, there's many where actually smoking has actually not declined, but it's actually, they're plateaued or been on the rise. So a lot more to do in prevention. We talked about the opportunities and screening. You highlighted potentially 90% of those who should be getting screened and not getting screened, and that was before the USPSTF expanded its recommendations. And then as you mentioned before, I think in treatment, there is a tremendous opportunity for us to really expand on this horizon in the categories that you laid out. So I'm optimistic, but share for me, what do you think the next 10 years looks like in terms of the battle against lung cancer? Any major insights or visions that you might have?
Dr. Gershenhorn: I think all fronts you just mentioned, we're going to get better and get more proactive with the screening, less smoking. That's going to help us a lot. We're going to get better with targets, and we're going to get more, more and more immune drugs out there and immune combinations. And I think we're going to start moving further away from using the chemotherapy, the cytotoxics. Again right now, we're not there yet, but I see a bright future. Lots of research is being done and I think 10 years from now, you're going to see those survival and we're seeing it already, the survival statistics are improving. We're going to see them continue to improve.
Pat Basu: I agree with you Dr. Gershenhorn and I just want to thank you again for your leadership in this field. Thank you for taking the time here today. Just a really terrific show that I know will be so valuable to so many people out there. I always liked to give experts such as you a chance to maybe end with a closing bit of advice or a closing thought for any of our listeners or patients that you might want to end with.
Dr. Gershenhorn: I think just in general, when you get a scan, whether it's a mammogram or a CT scan and there's something going on that's not right and your doctor thinks it might be cancer, I think first thing you need to do is arm yourself with a team of physicians and providers that really you can tell are going to be proactive, aggressive, move forward with treatment quickly, and spend the time to explain things so that it makes sense why certain things are being done. You want to be at a center that has access to research, access to new technology because a lot of times, when it seems like things are really, really bad from a cancer standpoint or you're really in a fairly depressed state because of what's happening, once you arm yourself and empower yourself with being educated as to what's happening, what your options are, and then you get proactive with moving forward with treating it, I think we can have a much more hopeful future.
Pat Basu: I love that thought, and I think an empowered patient is one of the best things that we can have in all of healthcare and you and I have both seen patients that transition and we help them transition that mindset from that initial lightening out of the blue sky into a empowered, okay, here's the next step and here's the support structure and we're with you together moving forward. I thank you from the bottom of my heart as a just such a compassionate physician who takes the time, who pulls out the whiteboard, who saves the pictures of his patients, and I can tell how much it means to you just as a human being. As a world- class doctor, again, can't thank you enough for leading the Lung Cancer Program at CTCA and really just on behalf of society, continuing to punch away at lung cancer as a disease and we know we're making strides. Thank you for taking time from your busy schedule. Thank you for taking time away from your patients to spend some time on the show. Really appreciate it Dr. Gershenhorn.
Dr. Gershenhorn: Thanks Pat, and thanks for the opportunity.