Virtual Support Group 2-17 – Transcription

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The following is a transcription of the Virtual Support Group which was held on February 17th, 2021. The format was a Q&A with Dr, Ash Tewari, MD. Chairman of Urology at Icahn School of Medicine at Mount Sinai. Moderated by William “Bill” Hatzichristos.

Bill: All right, everyone, welcome. We have a very large group on this Wednesday evening for the Man Cave Health Prostate Cancer Support Group. We really welcome everyone, we appreciate the registration, we appreciate you continuing to follow us. My name is Bill Hatzichristos, I am a part of Man Cave Health as a board member, I moderate these groups. We do them now once a month, we hope to increase that to a couple times a month, but based on feedback from you after this event, we will really customize the program to your needs, so I’m excited about that. Man Cave Health is a charity, we’re not a business. We do rely on donations, this is not a call-out for donations, but we want you to know that we are here to help men, women and families affected by prostate cancer. Rely on for education for doctor referrals, we have fresh programming coming, as I mentioned before, but it’s going to be based on your feedback and some other things that are going to be pretty exciting to, again, continue to support men’s health, specifically prostate cancer.

On, this call, we have Dr. Tewari who’s generous enough to give us the 45 minutes to really talk about men’s health, why it’s important to keep an eye on your prostate and how you go about doing that. Interest for me in Man Cave Health is I came down with prostate cancer at the age of 38, back then the robotic surgery wasn’t as sophisticated so chose to do a radical prostatectomy and I’m here to share with men the good, the bad, and the ugly of that approach. What happens before surgery, during and immediately after, and even 14 years later, what elements I still have, or how I’m still physically affected by that. But we can pick that up on another call, but today I do want to welcome Dr. Tewari who is here to say a few words. And then again, the way that we are going to take your feedback, and I see many of you are using the chat feature, find the chat feature on your screen, feel free to test it out, someone from Bermuda, how you doing? We are monitoring the chat feature and as Dr. Tewari starts to wrap up, we will call out and pose some of the questions that you are posting in that chat feature. So, given that Dr. Tewari, I’d like to turn it over to you. You’re on mute, sir.

Dr. Tewari: Thank you, Billy and thanks a lot to Tom, Mr. Milana for making this a dream come true because Man Cave is his dream, and he basically wanted to create an atmosphere where men can talk about their health and not be shy about it. As I have said it before, men take better care of their cars than they take care of their health and an initiative like Man Cave can possibly help them in discussing their health issues in a much more unhindered, a friendly atmosphere. That’s the theme about the Man Cave, but Man Cave has evolved into a resource for a good data, a good referral and interaction platform, like what we are doing today. And there is no better time to talk about prostate cancer then this, world cancer time was just few days ago. And we know about prostate cancer that while many men get diagnosed with prostate cancer and in most men, it is not going to impact their life.

There are small percentage of patients who really do need to tackle it and in spite of our best effort, last year, we did manage to lose 33,000 men because of prostate cancer. So prostate cancer continues to be a challenging problem, not just because it kills, but because there are many in whom it can impact the quality of life. Many in whom it can have an impact on the social and the psychological aspect. This is a very heterogeneous cancer. A cancer on one extreme may never need a treatment and on the other extreme, a person being diagnosed and within five years not living. This extreme of the contrast is what makes this cancer very unique, because it is important for us to differentiate between the bad actors from the good one, and there are many good ones. And that is the reason there are many biomarkers, many genomic testing available. Lot is happening in the front of imaging, a lot is happening in front of the novel treatments, all that combined this is an exciting time and platform like this allows us to share our new ideas as to what is happening in the field of prostate cancer. I’ll leave it back to you, Billy, to run the show. I’ll be happy to answer any questions, I’ll be happy to show the slides, but let this be an interactive platform. Thank you.

Bill: Sure, thank you Dr. Tewari. We do have some questions coming in, but before we jump to those, when we talk about the radical prostatectomy versus robotic or any other treatments that are out there, from your view, why do we pick one over the other?

Dr. Tewari: I think picking one over the other may not be the best approach, we need to find out to what exactly is happening in an individual patient, because this is one cancer, which has literally a millimeter difference between the outer edge of the prostate, where it can get into the nerves, or it can get into the muscles, which control urination. Finding exactly what is happening in an individual patient is a very important part of the puzzle. You need a program where they can have a good judgment as to who needs treatment and if a nerve sparing is even possible. That is the step number one. And then at the end of it, it’s about the surgeon, robot does give a little bit of a magnification, it gives an ability to do it in a bloodless feel, it gives the ability to do it with the smaller incisions, but at the end of the day, it’s the surgeons instruments which are doing something and sometimes those knowledges about the particular disease may not be appropriate.

I think 30% of the times we find that the cancer is actually escaping the capsule, even though we taught we knew everything about it. We would do an MRI, we would do an exam, we are doing a scan, but still, so it says decision between different modalities of treatment and I must say, not everything needs a knife, or in this market, a robot. There are many cancers who can be better tackled by not doing anything, or by doing something like in focal therapy or radiation of some kind Cyberknife, proton beam, or anything of that kind, or sometimes doing [inaudible 07:55] radical prostatectomy.

Bill: So, gentlemen and ladies on the phone, very, very important to really counsel with your surgeon and really understand what and why your surgeon’s recommending a particular solution. I found that with my experience. So, related to that, we had a question come in on post robotic surgery specifically on urinary continence. What, do we typically see? What are some of the stats out there? And then I’ll go to the next question.

Dr. Tewari: Actually, it’s very tricky that the prostate happens to sit between the bladder and the urethra. And there are muscles which control the urination to a point that the person is not leaking before the surgery or before the treatment and then after two, three hours of surgery, the bladder and those urethral muscles have to tackle it all alone. So, the risk of urinary incontinence can range in good hands, anywhere between five to 20% based on what kind of disease we are dealing with. People who are older, people who have a more aggressive cancer people who have some neurological issues, people who have had surgeries in their past, or people who have cancer coming close to the nerves and the sphincter, they tend to have a little bit difficult outcome than those who are younger, healthier, or have a more localized cancer.

Bill: Okay. Just a reminder to the folks on this call, please submit your questions using the chat feature we are monitoring that as they come through and we really want to answer any questions that you have on your mind, any concerns, we have a great forum here with Dr. Tewari. Dr. Tewari, the next question came in about leakage during intercourse. Is that normal as a side effect of any type of surgery? Is it more normal with one type over another?

Dr. Tewari: I don’t think there is a difference between the different types of surgeries, but this can happen. And the term we use it, is known as Climacturia. Climacturia, meaning during the orgasm, there may be a urinary leakage, and it’s very frustrating to the patients. And the same mechanism works. Patient may be reasonably continent in the daytime, but at the time when there is an ejaculation, the muscles relax and they get a urinary leakage. And the treatment is a couple of steps. Sometimes emptying the bladder before, sometimes having some medications, sometimes doing more Kegel exercises or biofeedback, sometimes not having wine coffee before that, and sometimes needing a surgery. All integrated manner.

Bill: We have another question, actually, a great question. And as I talked to friends and folks about prostate cancer, post-surgery you have a gentleman who post-surgery PSA came back zero it’s slowly rising now and it’s at 1.5. Is this a common occurrence? Does age have any factor on that or is there some other concern happening?

Dr. Tewari: A lot depends on the grade of the cancer, a lot depends on the aggressiveness of the cancer, a lot depends on the stage of the cancer. And I’m not sure if age has a major impact, but the grade of the cancer does have, and anywhere between 10 to 30, 40% of the patients can have a slowly creeping up PSA Bay after any treatment. You said 1.5 or .15?

Bill: No, 1.5.

Dr. Tewari: I think if PSA ever goes above 0.2, that is when we start the investigative process. And the investigative process, at least in my program includes an exam, reconfirmation of the PSA by an ultra-sensitive method. We use an MRI scan and sometimes a special kind of an ultrasound scan. We try to do a bone scan, we try to do an axumin scan, which is a PET scan. We were recently running a trial known as a PSMA trial. These all things they tell us if there is a true recurrence or is there a benign tissue which is producing PSA. Sometimes we do biopsy, sometimes we do cystoscopies and at the end of it, many times, we don’t see anything. Then we have to decide whether we want to observe it, or we want to treat it with hormonal-radiation.

Sometimes we see something. Sometimes we see something in lymph nodes, sometimes we see something in bones, sometimes we see something in liver and if we see something, then we have to make a decision in multi-disciplinary manner, whether we want to give hormones or a targeted radiation. This is a journey, but if supposing someone has a PSA of 0.2, 10 years, 15 years from the treatment and the original cancer was not very bad and patient is now about more than 75 years of age, we don’t have to rush into the treatment so early, we have to make a decision in a larger perspective rather than just jumping onto one treatment for everybody,

Bill: We have a 48-year-old gentleman on the line here, he had robotic surgery prior to surgery had a very healthy sex life and he is curious as to when do you think that he will return back to that normal sex life pre-surgery.

Dr: Tewari: A lot depends on again; the Gleason score and a lot depends on if cancer was aggressive or not aggressive. There are times if the Gleason is eight or nine, you cannot save the nerves. There are times when the cancer is already getting into the extra capsular space, even if you try to save the nerves, not everything can be saved. But if everything is all right, then we usually wait about a year, that’s when the sexual function return discussion comes in, but we start very early on a rehab process. Even few weeks after the surgery, we recommend having pills, we suggest that having an injection, we have a rehab program and that they should meet with an expert in the group. Every busy robotic program has some experts who just tackling with the sexual function recovery. So, that 48-year-old person should be in a rehab program. And we normally never talk about surgical interventions for about one and a half years. That’s the usual time when we start talking about that maybe we should think something beyond pills and injections.

Bill: Okay. Dr. Tewari, we’re getting a lot of thank yous directed to you. You have some patients on the line and they’re thanking you for everything that you’ve done for them. We just had a comment come up that the injections do actually work for this one gentleman, but we have someone who would love your opinion on genomic testing.

Dr. Tewari: Sure. Let’s think about genomic testing and then a broader concept. When we look at the cancer, the look of the cancer under the microscope is known as histopathology, but within the cancer cell, there is a machinery working and that is driven by the genes and the DNA. Sometimes the DNA is a more aggressive kind or a less aggressive kind. So, the genomic and discussion comes up in a patient like this 48-year-old gentleman who had cancer. If the patient’s cancer was a little bit aggressive, I would consider doing some kind of genomic testing, not just in the cancer, but in the blood to see if there is any risk factor involved in that family. If you have a family member, two members of the family had prostate cancer, mom had breast cancer, someone had pancreatic cancer, there is an added bit of a genomic testing we can do.

This kind of genomic testing is known as what we call germline testing in which we do the blood testing to find if there is an increased risk in the family for the prostate cancer. Sometimes the cluster comes in in breast cancer form, sometimes there are DNA repair pathway discussion, some BRC Gene discussion. So that is one kind of gene testing. Let’s keep that aside. Now, the second kind of gene testing comes up that a patient had a biopsy and biopsy came back negative, what to do at that time. There is a new kind of a gene test but it’s not really a gene test, what we call it’s an epigenetic test confirm MDX you can do in a negative biopsy to kind of predict what’s the likelihood this patient’s next biopsy will come out positive. That is another gene test. Then comes a patient who had a biopsy and patient had a Gleason six or a seven prostate cancer, what we call in early or an intermediate risk prostate cancer.

And most of the time in these patients, the discussion is whether to treat or to just observe. That is where the genomic testing come in role and there are three different gene tests we use. One is known as Prolaris, other is known as Onco DX, and third is known as a Decipher. All three tests give you a feel that this Gleason is going to behave more aggressively or not aggressively. And then comes in under the kind of genomic test, which you do when a patient has already had a surgery and we are suspecting that patient’s cancer is a little bit aggressive. Should we follow it very closely? Should we consider giving him adjuvant and treatment? And that is when we do the tissue-based testing known as the Decipher Test. These are the different kinds of genomic testing; we talk about it. Sometimes newer forms of PSA’s and newer form of the urinary testing are also coming, some people may call it genomic, but they’re not truly genomics, they are the biomarkers. But these are the gene testing, Prolaris, Decipher, Onco DX, SelectMDx, ConfirmMDx, and the BRCA gene discussion. Hope that answers the question for the person.

Bill: Dr. Tewari, we do have a ton of questions coming in and I’m getting to just a few of them, so we may need to have you back at another time sometime soon. We have someone who asked the question what’s your view on the use of immunotherapy where they’re a patient with BCR.

Dr. Tewari: I think that person is very educated and that person is doing a lot of research because BCR for everyone else means biochemical recurrence. When cancer comes back after primary therapy, be it radiation, be it surgery. It’s known as bio chemical recurrence, and that’s where the term BCR has come. The standard of care after surgery in a situation like this is that you should give hormones and give radiation. But many people are trying to avoid hormones and radiation in this setting and they are looking for alternative approaches. I normally put my patients if the PSA is barely high on healthy diet, exercise, some kind of an anti-inflammatory [inaudible 20:13] extracts and all this, and these are not even treatments. But there are certain immunotherapy trials which are underway and one of them, which we are working on is known as a RhoVac, which is a special kind of an antigen, which is seen in prostate cancer.

But I must say, this is not a treatment, these are the clinical trials. You can have clinical trials for a patient with a new kind of an antigen and that’s known as a personalized genomic vaccine. A couple of clinical trials going, and two of them happening in my own place. They are in IRB right now, but they should not be considered as a standard of care. Standard of care is what a medical oncologist, the radiation therapist or your urologist is telling, but there are certain new immunotherapy approaches are being discussed. One word of caution, prostate is not the most immunotherapy friendly cancer so we are working on strategies to make it a little bit more immunologically hot, but there are many trials coming up and then we happen to be doing a couple of them.

Bill: And if anyone on the line here wants to get involved in those trials, should they reach out to you with the information down below on the screen?

Dr. Tewari: Yeah, I think most people can get my emails, my cell phone easily, and they are through the IRB so there’s a couple of months before those immunotherapy trials. But there are new adjuvant immunotherapy trials going on in which in a more aggressive cancer, we inject something into the tumor, wait for six, seven weeks, eight weeks and then at 10 weeks we take the prostate out within hope that it will induce the immunity in the body so that the cancer recurrence will be less. This is again a trial and we have done many patients on that data is what is recruiting right now, but for the BCR should take couple of months.

Bill: Okay, great. Dr. Tewari, we have a question coming in just about statistics with what happened at the world trade center in September 11th. Is there a high number of prostate cancer patients that were on-site or a first responder that you’ve traded or do you know what some of the stats are?

Dr. Tewari: That’s real, I think first responders are considered to be a risk factor for people developing prostate cancer. I get to see many of these patients.

Bill: Okay. We have a gentleman here who has a concern, I actually have the same concern or the same side effect if you will. After my prostatectomy when you’re having sex and you ejaculate obviously, semen no longer comes out, but you now have what seems to be urine coming out. And the gentlemen is asking, is that in fact, what is coming out? And is there anything you can do to lessen that?

Dr. Tewari: A lot depends on the… you obviously have just mentioned that you had it long time ago so yours is not a time dependent discussion, but for someone who had it recently can wait easily year, year and a half, where do couple of bio feedbacks, could do couple of Kegels, things may get better, that’s the one point. There are certain medications which reduce what we call overactivity of the bladder. Overactivity of bladder gets better, they get a little bit less leakage, emptying the bladder is a good idea, using a condom is a good idea and sometimes just getting a sling procedure is not in out of discussion, but these are the medical discussions and they should have it with their doctors.

Bill: Sure, okay. I remember when I had my surgery, they said, oh, you’re not going need a colonoscopy for a really long time. Why? I don’t know, but they said that at the age 50, go ahead and get your first colonoscopy. Mine is actually scheduled for next month. But we have a gentleman who was asking after he has had a full removal surgery, how long should he wait to resume his colonoscopies?

Dr. Tewari: I may be off, but I usually six weeks to three months.

Bill: Okay.

Dr. Tewari: Meaning I don’t know the exact recommendation, but I have done it many times in patients beyond six weeks. I don’t stop them, but I can recheck on that.

Bill: Okay. And then going bac to the injection therapy that we talked about, we have a gentleman who’s saying, how long do those injections work and how it worked for, and what about GAINSWave therapy? Do you have any experience with that?

Dr. Tewari: I think injections are not just the treatment for erection, but they are the rehab also. Meaning it brings in oxygenated blood into the penile tissue so the likelihood that medicines, the oral pills will work better over time. That is the main reason for using the injection early on, but that may become the sole method of getting it so I think if it is working, you should continue using it. Recently they have been in what we call a shock wave therapy or an ultrasound therapy, and the data may be mixed, but in my program, and I have talk to the experts in my own team, they say anywhere between 20 to 30% of the patients get a response. There is a catch, this is not usually supported by the insurance companies so it’s an expensive thing and only 20, 30% of the patients get a response back. But that 20, 30% is worthwhile for those people who it works.

Bill: Okay. We’re getting a lot of feedback that Kegels are actually working for folks so really, really good advice there. We have a gentleman who would like your view on nanograms specifically to what Memorial Sloan Kettering might be doing in the area of nanograms. What’s your view on that?

Dr. Tewari: Are we using the right term nanogram or nano therapy or nano particles?

Bill: It’s nanogram came up.

Dr. Tewari: Mammogram is what I… I may be not getting the question, right, but I will turn it into a milligram discussion. And I think when ladies have a mammogram, men should have a mammogram and that [cross-talk 26:58] of the prostate is what I call it.

Bill: It’s Nano with an N, so nanogram

Dr. Tewari: Nano therapies, there’re nanoparticles, there’re nano based focal therapies but nanograms, I’m not aware of.

Bill: How about Nomogram?

Dr. Tewari: Now we are talking.

Bill: Okay, let’s do that. Let’s go with that one.

Dr. Tewari: At least I didn’t explain something which I didn’t know.

Bill: No, it’s me and my interpretation of typos.

Dr. Tewari: Nomograms are the algorithms which predict something. And the Memorial nomogram there are CRPC there are nomograms from European Congress, there are nomograms made by our own group where we predict if someone gets a biopsy, what’s the likelihood of finding cancer. Second, someone gets a biopsy, finds a cancer, what’s the likelihood that that cancer will be aggressive. Then you get a treatment, what’s the likelihood that the cancer will come back. And one of the very famous persons from Memorial who is now at Cleveland Clinic, his name is Michael Kattan. Kattan nomogram is very famous, there is one nomogram, which is very famous from Johns Hopkins. It’s known as the Partin Nomogram. So, these are known as nomogram is in predictive model, predicting an event before it has happened. Person puts in their PSA, their biopsy, their age, their grade, their rectal exam findings, sometimes their MRI and it turns out that based on 10,000 patients in the pass, what’s the likelihood that this patient’s cancer will behave this way or that. That’s what’s known as nomogram.

Bill: Okay.

Dr. Tewari: We are actually working on something, which is very cool. We call it artificial intelligence-based models. We are using a neural network and AI models to predict the same kind of a thing, so next year, hopefully we will have a little bit more information. We also have a nomogram for predicting whose cancer is trying to come close to the edge. It’s an extracapsular extension. One of my Italian fellow Alberto Martini has put together that.

Bill: Yeah, I guess with the right amount of data, we could really figure things out and it becomes more predictable. I find it an interesting question because I think I can answer it not being a physician, but we have a gentleman who is taking, I’m going to pronounce it wrong Sildenafil occasionally for erections and it’s very effective. Should he move towards injection therapy? I would say if it’s working, why sweat? But Dr. Tewari, what do you think about that? Sildenafil is working, should he move towards injection therapy?

Dr. Tewari: I would say don’t change a winning game and just thank his doctor that the pills are working. I think that’s good news.

Bill: Right. If it’s not broke, don’t fix it.

Dr. Tewari: Yeah. And then pill the least amount of intervention, so something is going very right. He should just buy more flowers to the partner.

Bill: So, if it’s not effective, let’s say we have a scenario where that medication is not effective, you’re suggesting go right to speak to a physician, right?

Dr. Tewari: Yeah, I think if medications are not working sometimes one other trick you need to know is that these medications like Sidenafil, you have it empty stomach. So, people need to know that don’t eat a heavy meal at that time, don’t have some alcohol in the belly at the same time, so that timing is an important discussion. Sometimes mixing different kind of medications, one may not work, the other may work. Sometimes Sidenafil comes in very small doses so you need to get to the right amount of doses that doctors can guide. Then comes the discussion about the injections and in an injection, there are bi-mix, tri-mix, qua-mix different kinds of mixtures which are there. There are more as I talked about, the sound wave therapy is there, but they are known as STEM cell therapies. Somehow people are trying different kinds of… but this is not a discussion on a webinar, this is a discussion dedicated with a sexual medicine expert and there are many in different parts of the city and in Northeast that they should sit down with someone and talk about it and many new things are going on.

Bill: Okay. We have a comment from Mark. Mark. Absolutely. We would encourage you to invite friends, women, men, to join this group next. We hope to have Dr. Tewari on again in the future. Getting a lot of positive feedback on the discussion. So, Mark, the answer is yes. Continuing on the conversation about injections, what if they don’t work?

Dr. Tewari: If injections don’t work, then don’t work is a function of is there a right dose or could increase dosing work. Sometimes a different compound can work, sometimes it’s not been frozen, that can be an issue, but sometimes it doesn’t work. If it doesn’t work, then you have to think about the other options. And the pumps are another option, and the penile implants are the other options.

Bill: I remember when I had these concerns and I talked to doctor about not being able to get erections. He said Bill, don’t worry, there’s pills for everything out there. He said there’s purple pills, there’s yellow pills, there’s other pills. He said you just have to find the one that works best for you.

Dr. Tewari: But unfortunately, sometimes none of the pills work for certain patients. I think that’s the challenging part of prostate cancer is. And then you have to have a plan in place for what to do if pills don’t work and injections don’t work and what are the operations and all those things. So, this is a whole gamut of tools need to be available for the patient.

Bill: Sure. Dr, Tewari, for a couple of months ago, we had Kate Motz on the support group and she talks specifically around diet, and she calls it gut health or health from mind to mind to toes. From where you said, what do you tell your patients about diet, whether it’s pre-op, or post-op just healthy living, do you have those conversations? And if you do, what do you recommend?

Dr. Tewari: I really am a big believer of a diet and we have two people have interacted a lot, in fact, three people. One is the Jillian who works in my program and she’s a nutritionist and an integrative medicine person. I often deal with Dr. Espinosa, Geo Espinosa. I deal with Aaron Katz and Philippa Cheatham. These are the people of my mindset who are in the prostate cancer field. But I personally think less red meat, less animal fat, less sugar, more blueberries, more pomegranate seeds, and lots of exercise, that I think is the recipe. We have a bootcamp we talk about when we put patient on an active surveillance. My usual take is that I do the surveillance and patient does the activity. And activity is three miles a day, keeps doctors away. Exercise is good, sweating is good, going to gym and doing a control exercise is a good idea and I’m a big believer on that.

Bill: And what about dairy? Is low fat dairy okay? Or almond milk or any of that stuff?

Dr. Tewari: I think dairy is not the best. Very simplified version is what is good for the heart is good for prostate. There are only two organs in the body which are heart-shaped, heart is heart and prostate. I think diary is also not that friendly, but I’m a big believer of also one more thing. Never say never, never say always. Meaning do it in moderation. You cannot become totally vegan, cannot change your lifestyle totally but there is one guy who has done a lot and you guys should know Gabe Canalis. Gabe Canalis is another prostate cancer survivor who is very young and is very active in the field and he talks a lot about the diet and nutrition. When I talked to the other experts, the summary comes to be that… I’m not talking about any exotic diet. it’s just cut down on sugar, cut down on fat and definitely not too much of Indian food.

Bill: Yeah. We have someone here runs three miles a day went to a vegan diet, and so far since April of 2019 the PSA is undetectable so congratulations.

Dr. Tewari: It happens. I have seen this kind of thing, but it’s not in lieu of a medical advice and then not lieu of real treatment, but losing weight and keeping in very healthy mindset is a great idea.

Bill: Yeah. Dr. Tewari, we’re going do two more questions and then we’ll wrap up the call since we’re coming up to the quarter hour. I guess the FDA has recently approved something called PSMA do you know when that will become generally or even readily available?

Dr. Tewari: So, we were the clinical side for the PSMA trial and there is one PSMA which was developed by the UCSF, UCLA and there was one more institution. I think that is going to be available very soon. We have currently a PSMA trial going on right now for an aggressive prostate cancer patient who are having a treatment being considered, meaning this is not for the recurrence, this is for the people who are coming early on for a treatment and we are doing it, but it won’t last more than a month or two. My answer is hopefully in the next six months, we should have a PSMA available commercially. Right now, something close to that is known as an axumin scan that is available through most insurance companies, but the PSMA, we have done a lot of them.

Bill: Okay. For those of you folks who did not get their question answered, please hold those for a future session or contact Dr. Tewari directly either he or someone on his staff will answer those. We have our next virtual support group, will be on much third at 6:00 PM. Again, we’d love for all of you to attend again, and yes, absolutely invite friends, partners, anyone who you think can benefit from this type of discussion. Dr. Tewari I’m going to give you the last word, so to speak. Any final comments for all the men and ladies that are on the phone?

Dr Tewari: My thing would be that we kind of try to understand what men go through or the families go through as a couple when they are fighting this battle, it’s not easy. But I also want to thank all the scientists and physicians and support groups who are getting together to find a new solution. So, don’t give up, stay strong, maybe something new will come up and we are definitely trying to look for a better solution. Thank you again. Thanks for giving me a chance to share my thoughts, my biases, and hopefully I can help again.

Bill: Well, on behalf of Dr. Tewari, Tom Milana, and everyone else had man-cave health, the moderators that are on the line with us I personally want to thank everyone and I hope to see you and talk to you all very, very soon.

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