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Late Effects of Cancer Treatment
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(ANNOUNCER)                   

Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association; an association of independent, locally-operated and community-based Blue Cross and Blue Shield plans, supporting solutions that make quality, affordable healthcare available to all Americans.

 

(MUSIC)

 

(DR. PETER SALGO)          

Welcome to Second Opinion, where each week you get to see firsthand how some of the country’s leading healthcare professionals tackle health issues.  These are issues that are important to you.  Each week our studio guests are put on the spot with medical cases like this one, based on real life experiences.  By the end of the program, you’re going to learn the outcome of this week’s case and we hope that you’ll be better able to take charge of your own healthcare.  I’m your host, Dr. Peter Salgo, and today our panel includes Dr. Sandy Constine, from the University of Rochester Medical Center, Dr. MaryEllen Nerz-Stormes, from Bryn Mawr College, Dr. Jeffrey Wefel, from MD Anderson, Dr. Jame Abraham, from the Mary Babb Randolph Cancer Center in West Virginia, and our Second Opinion primary care physician, Dr. Lou Papa, from the University of Rochester Medical Center.  Alright you’ve met everybody; it’s time to get right to work.  Our case today is about Chris.  He’s a thirty year old man, very fit, who was diagnosed five years ago with testicular carcinoma.  It was metastatic to the lung and to the brain.  Not the best diagnosis.  He was, however, treated with orchiectomy, which is they removed his testicle, radiation and cyst platinum.  Lou what’s that?

 

(DR. LOU PAPA)                        

Cyst Platinum is a chemo therapy agent that they use regularly in a lot of cancers, especially in the testicular cancer. 

 

(DR. PETER SALGO)          

It’s a powerful drug.

 

(DR. LOU PAPA)                        

Very powerful but it’s very effective. 

 

(DR. PETER SALGO)          

On the other hand, it’s a nasty disease. 

 

(DR. LOU PAPA)                        

It’s a nasty disease.  You’ve got to fight nasty with nasty.

 

(DR. PETER SALGO)          

Chris’ treatment was considered successful and at the end of his treatment period the evidence was, and I’m using the phrase that they used in the chart, clinical cure.  He was able to return to his life.  He works as a mail carrier for the postal service.  And that was five years ago.  But today Chris is not doing quite as well as he was or thought he would be doing.  He’s noticed a tingling in his feet, tingling in his fingers, and that tingling has progressed over a few months to burning pain.  So Lou, you’re his PCP.  He’s in your office.  He’s worried that his cancer has come back.  Does that worry you?

 

(DR. LOU PAPA)            

It does worry me.  I mean that’s probably not at the top of my list just because what he’s describing seems mostly peripheral that describes more of a nerve condition.  And there’s lots of things that can cause that but sometimes the chemotherapy can cause that. 

 

(DR. PETER SALGO)          

So I can tell you that he saw his oncologist and his PCP.  They ran some tests and they determined he’s still cancer free.  That’s the good news.  They decided to send him to a neurologist for his current symptoms and he gets a full neurologic exam and they give him a tricyclic antidepressants, TCA’s, Gabapentin and eventually a narcotic pain reliever for the burning pain he’s experiencing.  So my inference from this is that this pain pretty much. 

 

(DR. LOU PAPA)                        

It’s not, yeah, lots of times these pains can be very debilitating. 

 

(DR. PETER SALGO)          

None of these drugs, including the narcotic seems to work very well.  What’s going on here?

 

(DR. JAME ABRAHAM)

It’s very common we see in that, with our patients exactly what’s happening here, an intractable or severe nerve pain.  That’s due to platinum or taxol or taxane or axial platinum, which is, so, and all those things can cause severe nerve damage. 

 

(DR. PETER SALGO)                      

How on earth can pain be so bad narcs don’t work?

 

(DR. JAME ABRAHAM)

Nerve pains different from other pains.

 

(DR. PETER SALGO)

How so?

 

(DR. JAME ABRAHAM)

So when we talk about, like to say whistle pain, something happening in the chest or liver or lung or muscle.  That can be probably controlled with a narcotic medicine.  But neuropathy pains are highly sensitive and it’s actually has a different feel.  That’s not an exactly treated with a narcotic.

 

(DR. LOU PAPA)

So that’s why he’s on these other drugs, the Tricyclics and the Neurontin have a little bit more success in dealing with that almost electrical type of pain.  And it’s typical not only with cyst platinum but a lot of neuropathies from other causes are that way as well.

 

(DR. PETER SALGO)

Neuropathies meaning nerve injuries. 

 

(DR. LOU PAPA)

The nerve injuries with that tingling.

 

(DR. PETER SALGO)

I want to be very clear, okay.  He got a lot of chemicals, right, because he had a life threatening disease.  I mean at the time he got them that seemed like an unavoidable choice.  But what you’re saying is that the pain he’s experiencing now is a direct consequence or likely to be so of a life saving therapy that he had.  Is that true?

 

(DR. LOUIS CONSTINE)
The first priority, of course, is to establish the proper diagnosis and it can be very difficult in patients with peripheral neuropathies.  But if they have now, his physicians, have done what they can do to investigate other possible causes of the pain and if they haven’t been able to discover another cause and it’s rational to consider this a peripheral neuropathy.  And what that just simply means is the nerves which are running through the various limbs of the body have been effected by the chemicals and then trying to treat it.  But I think what you’re really describing here is the situation where we all have a patient who has a cancer, and fortunately in this situation we can be reasonably optimistic that that patient is going to be cured. But then what are going to be the long term consequences of the cure?  And are those consequences going to be something that enable the patient to live a meaningful and high quality of life or are those consequences somehow going to compromise that?

 

(DR. MARYELLEN NERZ-STORMES)

I have peripheral neuropathy, so I have firsthand experience with it.  But when I was on taxane’s it was more severe.  It was more like numbing and pain.  And when I did take Neurontin it really did nothing.  But yet I’ve had friends who have had peripheral neuropathy from the platinum and did just fine.

 

(DR. PETER SALGO)

Tell me your story a bit.

 

(DR. MARYELLEN NERZ-STORMES)

I have metastatic breast cancer for nine years and I was first, kind of the standard treatment of the time was to give people who have or who are her two three plus, Herseptin and Ataxin.  And I was given Herceptin and Ataxin.  But the taxatier.  And taxatier does cause neuropathy. 

 

(DR. PETER SALGO)

Right.

 

(DR. MARYELLEN NERZ-STORMES)

And it’s just like a very common phenomenon. 

 

(DR. PETER SALGO)

You had surgery though.  You had surgery for your breast cancer?

 

(DR. MARYELLEN NERZ-STORMES)

I had very little surgery. And I traveled far and wide to have breast conserving surgery because they refused to do it in my hometown.  And I had an auxiliary node dissection that was unnecessary because once you find out your tumor had spread, and it had spread to my bones at the time.  I realized I never needed surgery and I’ve never had surgery again even though I’ve got lots of breast tumors. 

 

(DR. PETER SALGO)

But what you have in common with our patient.

 

(DR. MARYELLEN NERZ-STORMES)
Yes.

 

(DR. PETER SALGO)

In our case here.  Is that you had surgery, followed by chemo.

 

(DR. MARYELLEN NERZ-STORMES)

Yeah.

 

(DR. PETER SALGO)

Followed by what sounds like a peripheral neuropathy.  The question I have for you is, Chris’ doctor told him, that MD that’s what he thought was going on, he had a peripheral neuropathy. But do you think anybody warned Chris that he could experience this from the chemo?  And did anybody warn you, you could experience this?

 

(DR. MARYELLEN NERZ-STORMES)

I was, in the early stages, I was in too much trauma to absorb all that.  And I think I was told.  I am.  At this.  You know, eight years later I doubt I remembered this or I even absorbed it.  And I think one of the things that’s absolutely difficult, no matter what your education is, the first two or three months when you have, when you’re treated you don’t absorb a lot of the information.  And you particularly are not focused on the ancillary problems.  Because when you’re told it’s highly unlikely that you’re going to survive.  I was told I was not going to survive or I might survive two years.  The only things you care about is living.  For, you know, living.  You don’t care what happens to you.  You don’t care if they cut off your breasts.  You don’t care if you’re in pain.  You know.  So I was so unaware of that in the beginning.  Later I was very cognizant of it. 

 

(DR. PETER SALGO)

The docs I know would regard Chris, would regard you, as a success story.  This is advanced breast cancer, testicular cancer, still alive.  Is this a success story as far as you’re concerned?

 

(DR. JEFFERY WEFEL)
I would say absolutely because I would agree with you.  I think it’s very important to shepherd a patient through that process, to get them to the other side where there maybe some survivorship issues and we’re making progress in addressing those and there hopefully will continue to be other ways to address those issues but we first need to get them across that barrier, across that boundary.

 

(DR. LOUIS CONSTINE)

It’s an ethical imperative that we talk to our patients about what might be the long term affects of the treatments that they’re going to receive.  Having said that, at the time they are diagnosed our goal, as is their goal, is usually to cure them with disease than have a time in the future where they can celebrate that survival but yet perhaps be facing significant affects on their quality of life is a point we’re all looking for. And right now there are twelve million survivors of cancer.  And so this is a remarkable problem, and thank goodness it’s being recognized as something we need to understand and do better with. 

 

(DR. LOU PAPA)

But I think it’s interesting because the transplant people will tell us, and it’s a similar situation of people with life bearing.  We’re going to treat your condition but realize that we’re going to trade one disease for another, potentially.  The one that we’re going to treat is life threatening. 

 

(DR. PETER SALGO)

Right. You’re breast cancer.  And a lot of breast cancer survivors complain about a little fogginess.  You know they call it chemo brain or chemo head.  Has that been a problem for you?

 

(DR. MARYELLEN NERZ-STORMES)

Yes.  I think that in the beginning it was very much due to just the trauma.  And it’s very hard to extract, it’s the trauma you’re going through and from the drug you’re getting.  Now the taxanes and herceptin do not cross the brain barrier to any significant extent.  And I believe this is pretty, in my opinion it’s associated with drugs that cross the brain barrier.  However when I later went on capecitabine I was very definitely foggy.  I describe it as being foggy, easily distracted and sort of, I get very upset about confusion.  You know, I’m the absent minded professor anyway. 

 

(DR. PETER SALGO)

I know you said that you, in the first few months, really weren’t hearing everything. 

 

(DR MARYELLEN NERZ-STORMES)
Yeah.

 

(DR. PETER SALGO)

So did this all come as a surprise to you, including the fogginess?

 

(DR. MARYELLEN NERZ-STORMES)
I think the thing that surprised me the most was a little phase I left out in there was I was forty-two years old and I went through premature menopause.  That was the thing that absolutely, I was told nothing about.  And I mean no disrespect to my doctors.  I think their view was you got this cancer, it’s probably fatal.  But I was suddenly going through menopause, which also affects your brain tremendously.  And again I have trouble extracting that out.  Like how big effect did that have.  So to me, of all the things that happened through the years.  That was the big surprise. And then after that the other things seemed like small potatoes to me.

 

(DR. PETER SALGO)

Well Chris is as surprised as you were.  He wasn’t prepared for having problems so long after his cancer.  In fact six years now after his treatment his pain is worse than it was.  And on top of that he’s complaining about the following symptoms – touching anything cold causes severe burning pain.  Are you surprised by this?

 

(DR. JEFFERY WEFEL)

Yeah I think these.

 

(DR. MARYELLEN NERZ-STORMES)
I don’t know.

 

(DR. JEFFERY WEFEL)

These neurotoxicity’s and these peripheral neuropathies are very commonly associated with these platinum associated regimes in the neuropathies as you described, the numbness and tingling, and increased sensitivity to cold.  Those are very common descriptions that I hear in my clinic.

 

(DR. PETER SALGO)

Chris, Mary Ellen, both adults when all this hit.  What about kids?  We give kids some serious therapy for seriously life threatening diseases and it’s just worth putting out there, if you ask any parent of a kid with leukemia, lymphoma, would you trade twenty years from now your child being alive with some neurologic problems.  There’s no question, the answers yes.  But do kids have a problem that’s different than adults going forward?

 

(DR. LOUIS CONSTINE)

Children certainly have an increased vulnerability to the ill effects, the long term side effects of treatment.  The priority, again, is almost always to cure them and to help them achieve a time in life when these other effects might become a problem for them.  Having said that, the, a child has a full range of, a huge spectrum of possible side effects to deal with in the future.  And those range not from growth and development to sexual maturation to neuro-cognitive acumen to secondary cancers, which really is probably one of the most worrisome.  It’s what we call the agony of victory, is when a child survives only to develop another cancer, cardio damage, damage to the heart or damage to the lungs.  And so all the tissues of a developing child are vulnerable to the side effects of the treatment and the radiation and it’s our job if, to determine the idea strategy for treating that child, which will allow them to survive the cancer with the minimum of side effects so they can have the maximum quality of life.

 

(DR. PETER SALGO)

Without regard necessarily to the chemo or radio therapy, surgery alone has problems.  Right?  I mean?

 

(DR. JEFFERY WEFEL)
Sure.   As a neuropsychologist when you’re working with patients who have tumors within the brain, clearly surgery is designed to eradicate those, that population of cells that they can see on the scan or they can see inter-operatively.  But there’s always risk of injuring normal tissues and causing changes in cognition as well. 

 

(DR. PETER SALGO)

And you alluded also to the potential for another cancer.  Is this a consequence of the chemotherapy?

 

(DR. JAME ABRAHAM)

It can be.  It can be.  Some of the chemotherapy can cause cancer but this, Chris.  I think Chris’ doctor treated him appropriately but as Mary Ellen said, sometimes some of these medicines don’t work.  And Gabapentin or a narcotic don’t work.  Usually I send many of those patients for physical therapy.  I mean I think the physical therapy is one we need to explore that more often.

 

(DR. LOU PAPA)

But what’s very important for somebody like this though is not to under estimate the degree of pain that they’re in.

 

(DR. JAME ABRAHAM)
Right. 

 

(DR. LOU PAPA)
And also not to, what happens with some of my patients is that they’re reminded by physicians and family but you’re alive.  And it makes them feel that much more angry and worse because they’re alive. And they’re grateful of that but they’re quality of life right now is not that good.

 

(DR. LOUIS CONSTINE)

I wanted to come back to your question about the second cancers because I think this is an incredibly important area for physicians and patients to understand the likelihood of developing another cancer after a first cancer has to do with several issues.  One the under, the reason that person developed the cancer might be their genetics or certain kinds of exposures to toxins can predispose them to the development of another cancer. The chemotherapy that’s used to treat the cancer can have an effect of the tissues of the body to predispose them to another cancer.  The radiation therapy that’s given to help cure the cancer can cause other cancers later in lifetime.  And so it’s absolutely critical that both the patient and the physicians, both the oncologist and the primary care physicians recognize this because that patient will likely need some kinds of surveillance throughout his or her lifetime and if we fail to do that we may do a terrific disservice.  You don’t want to have somebody survive only to say, oh gee, I’m just going to die of another cancer.  I shouldn’t have even bothered to go through this because it isn’t like that at all.  Most cancers that might develop subsequent to the first cancer should be curable in this day and age, not all.  And this gets into issues of leukemia versus other kinds of cancers that we call solid tumors.  But certainly when you finish therapy, when you finish therapy, all patients should be given what we call a pass bar for care.  They should be informed as to what their cancer was, what the nuances of it were, what their treatment was, what are the potential side effects, and how should they be evaluated over the rest of their lives.  And that information should be something that’s also discussed with the local physicians. 

 

(DR. PETER SALGO)

Let me pause for just a moment here because we’ve covered a lot of ground. Let’s sum some of this up.  Treating cancer involves powerful therapies and these therapies can target the cancer.  The goal, of course, is curing the cancer. The problem is that some of these therapies, as powerful as they are, can leave a wake of long term physical and mental effects but often times patients are not prepared for. And some of them can be quite severe.  So, at the very least, patients should be made aware of this.  We are talking about Chris.  He’s the patient in our chart who is experiencing pain and neurologic symptom; it’s a late effect of his cancer therapy.  And Mary Ellen, you’re here with us as well, who, you’ve been getting chemotherapy for eight years and it’s now seven years, by the way, since Chris had his cancer treatment.  And he has now become ataxic and is having a terrible time with balance.  What’s ataxia? 

 

(DR. JEFFERY WEFEL)
It’s a difficulty with fine motor movements, often times arriving when there’s injury to the cerebellum that causes over reaching or.

 

(DR. PETER SALGO)

Brain injury.

 

(DR. JEFFERY WEFEL)

Under reaching. 

 

(DR. LOU PAPA)

Like a drunk would walk.

 

(DR. PETER SALGO)

Could anyone have predicted these problems going forward at the time he was being treated?

 

(DR. JAME ABRAHAM)
Not everybody develops this chemo brain and not everybody develops the neuropathy.  Who predict and who develops this?  Now that’s actually an activator for search.  Only twenty-five percent of the patients develop memory problems and are probably twenty or twenty, well no probably thirty percent of patients develop a long term side effect such as neuropathy.  So we don’t know.  At this point we don’t have a test to predict who develops what side effects. 

 

(DR. PETER SALGO)

Are these side effects preventable?

 

(DR. JEFFERY WEFEL)

That’s a great question.  I would agree with what Jame said that a lot of the research in this area, particularly around cognizant issues, are in their infancy.  The incidence of cognizant changes after treatment with typical chemotherapies and typically this is studied in breast cancer patients or has been most well studied in breast cancer patients, has varied up to seventy-five percent of patients in samples have been found to exhibit changes in cognizant function after treatment. 

 

(DR. PETER SALGO)

Seventy-five percent, big number.

 

(DR. JEFFERY WEFEL)

Up to seventy-five percent, that’s exactly right.  Now the incidence, of course, if quite squishy.  The number of people that have actually been.

 

(DR. PETER SALGO)

Squishy, is that in the medical textbooks?

 

(DR. JEFFERY WEFEL)

I think it’s medically reasonable to say that.

 

(DR. LOU PAPA)

It’s from Greeks. 

 

(DR. LOUIS CONSTINE)
When you ask the question, is it preventable?  The first question, of course, is why did it happen?  Can we predict it?  And so there’s probably underlying genetics of a patient which relate to their risk of developing a side effect.  And we also, for example, know that chemotherapy and radiation to the brain, for example, causes certain kinds of problems. And we’re beginning to understand how that happens.  What’s going on in those hills?  And as we begin to understand that then we can begin to sensibly investigate a direction for either preventing the problem and/or managing the problem more effectively. So sure there’s a bright future. 

 

(DR. PETER SALGO)

Let me turn this around, because you’re the one whose sitting here who knows what it feels like from the inside looking out.  You’re eight years out.  I think it’s actually nine years.

 

(DR. MARYELLEN NERZ-STORMES)

Nine today.

 

(DR. PETER SALGO)

Today.

 

(DR. MARYELLEN NERZ-STORMES)
And thanks to my wonderful team. 

 

(DR. PETER SALGO)

The reality of all this is that twenty-five years ago, thirty years ago, if you had had the diagnosed you had you probably wouldn’t be here. 

 

(DR. MARYELLEN NERZ-STORMES)

True.

 

(DR. PETER SALGO)

You would not have survived out nine years. Cancer treatment does work.  But you’ll forgive me.  If I listen to you there’s some anger.  Are you angry?  And if so, why?

 

(DR. MARYELLEN NERZ-STORMES)

There’s definitely a period where I was getting, I was taking drugs to treat side effects to treat side effects to treat.  You know it was like this kind of cascade of things.  I’m not particularly upset about the neuropathy, things like that, I can live with those.  I think maybe where you heard the anger was I felt I shouldn’t have had surgery.  And even in my position in life, I’m fifty one years old but still, it bothered me.  A lot of people say why does that bother you?  It just bothers me that I had to go through a deformity.  When you start they kind of act like it’s not biggy to have this surgery.  Then I find out I didn’t really need to have it.  So why did I have it?

 

(DR. LOU PAPA)

I think it’s warranted because I think in some respects you’re talking about the chemotherapy that really was the thing that had the impact on your disease, whereas the surgery was really kind of this.

 

( DR. MARYELLEN NERZ-STORMES)
I didn’t need it.

 

(DR. LOU PAPA)

Red. 

 

(DR. PETER SALGO)

Well maybe I misapprehended you.  I thought you were really.

 

(DR. MARYELLEN NERZ-STORMES)
Tell me what I was angry about.

 

(DR. PETER SALGO)
That you were angry about the fact that this chemotherapy was having a tremendous impact, it was disabling in many ways.  It affected your thoughts and you didn’t like it. 

 

(DR. MARYELLEN NERZ-STORMES)
I think I’ve grown to adapt to it.  So I think so much time has gone by but in the beginning.

 

(DR. PETER SALGO)
Yeah.

 

(DR. MARYELLEN NERZ-STORMES)

I was definitely angry about it.  And I definitely.  It definitely interfered with my ability to do my work. I really love to do my work.  I was in a place of sort of psychologically where I was so detached from my children; I was just kind of watching them through a plate glass window because I thought I wasn’t going to survive.  I would have things I had to do at work and just go, so what.  Why should I rewrite that, I’m not going to be here in a year.  You know sometimes I would just have this, given.  And no one would look at me and say I was negative, I was working.  Those kinds of things.  I think now I really have adapted a lot in the last.  It takes a while to adapt.  You don’t get used to a diagnosis in five minutes.  I think it takes.

 

(DR. PETER SALGO)
What I’m hearing is communication.  In other words,  Chris needed to be told if he was not told. 

 

(DR. MARYELLEN NERZ-STORMES)

Yeah.  More communication. 

 

(DR. PETER SALGO)

And then during, working through his cancer he needed to hear more of that.  You might have been told you didn’t remember.  Are we doing a good enough job in communicating?

 

(DR. MARYELLEN NERZ-STORMES)

No. 

 

(DR. PETER SALGO)

I heard that.

 

(DR. LOU PAPA)
Well I think part of it is the situation at hand.  It’s.  No that retrospect scope has such wonderful twenty/twenty vision and I’m just thinking of myself.  If I’m told I had metastatic testicular cancer it’s going to be really hard for me to just kind of weight those, the consequences of the treatment if that’s the only thing that’s going to get me to experience those symptoms.  So I think it’s really hard.  You can make that as crystal clear as you can to the patient but, you know, if the house is on fire you’re first step is to get out of the house.  This is not like weighting some, you know, equally balanced issues.  One of them is going to kill you.  And the other one is the result of the treatment that’s going to save you.  It’s. 

 

(DR. JEFFERY WEFEL)

I think another important thing though is how you interact with the patient when they bring your, they bring this to your attention, and they say this is an issue that I’m now having.  You may or may not have warned me about it but this is now an issue.

 

(DR. JAME ABRAHAM)

What I tell my patients is I’m going to be with you and whatever side effects you’re going to face we’ll work that through because I can’t predict you’re going to have neuropathy or heart failure or memory problems.  But I’ll help you through this.

 

(DR. PETER SALGO)

What I hear you saying is key word I’m going to be with you.  That’s really important.  Let’s pause just for a moment and sum up what we’ve been talking about.  Treatments for cancer have allowed people to live long lives for years after their diagnoses.  But once the cancer treatment is over long term follow up care is very important.  Doctors have to be with you.  If you’ve been diagnosed with cancer you need to learn about late and long term effects of your treatment so that you can know more about your health as a cancer survivor and you can help your doctor help you and you can communicate better, I think, and know what to expect.  I could tell you that Chris continues to receive treatment for his neurologic problems.  He’s become physically disabled.  He is unable to continue work as a mail carrier and he’s actually sought retraining for a different career.  He’s working in the computer field now so he doesn’t have to be on his feet so much.  And by the way, that’s going very well.  Now Mary Ellen, I don’t want to leave this without some word of advice from you, the cancer survivor here on the panel. What would you tell people?

 

(DR. MARYELLEN NERZ-STORMES)

I attribute my survival to team work that I developed with my doctor over the years.  And I think communication is extremely important and what I learned was to ask lots of questions, do tons of reading, be extremely well educated, and to the point where my doctor trusted me more.  He trusted my view more.  And as time went on we really did develop a team relationship where he listened to what I said and I listened to what he said.  I think oncologists have an incredibly complicated job.  It’s a multifaceted job and that’s what part of the problem with the ancillary treatments.  Why you don’t get as much information about the answer and the focus is on the chemotherapy.  And they have a lot of things they have to do but I think.  Over time it’s a type of relationship where you really can.  You really can work together.  And I think when you work together you do start to really communicate and understand things.  It is a process, it’s a journey.  And you learn along the journey and there’s no.  I don’t think there’s any way to go back to the beginning.  At the beginning everything’s going to be perfect.  I think you have to face it like that, it’s a journey and you’re going to develop but you’re going to keep working at it.  And I fortunately had a great physician who motivated me.  And I just kept.  He made me part of the team and I had jobs and I was working.

 

(DR. PETER SALGO)
Well we’re thrilled you’re still here, unfortunately however, the clock has expired on our broadcast.

 

(DR. MARYELLEN NERZ-STORMES)

Okay.  I hope it went okay.

 

(DR. PETER SALGO)
But you can continue this conversation on our website, secondopinion-tv.org where you’ll find transcripts, videos, more about the late effects of cancer treatment and other healthcare topics.  Thank you for watching, thank all of you for being here most of all you. 

 

(DR. MARYELLEN NERZ-STORMES)

Thank you.

 

(DR. PETER SALGO)
It’s not easy necessarily to talk about your disease in public and I appreciate it. We all do.  I’m Dr. Peter Salgo, and I’ll see you next time for another Second Opinion.

 

(MUSIC)

 

(ANNOUNCER)                   

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(ANNOUNCER)                   

Second Opinion is produced in association with the University of Rochester Medical Center, Rochester, New York.