HPV and Caring For Women With Cancer (w/Dr. Lois Ramondetta)

– What is up Zpack it’s your boy ZDoggMD, we are doing something different today, it’s inside the doctor studio with ZDoggMD. It’s a different setup that we’re using, we have an amazing guest that I’m gonna talk about in a second but a quick bit of housekeeping. This is gonna be a long in-depth conversation that you will really really be interested in. So if you don’t want to watch video and burn through your phone battery, you can get this on a podcast on iTunes, Stitcher, or SoundCloud. Just search incident report and we’ll put links in. If you could do us a favor and actually review that podcast, leave a little review, it helps us bump up the charts. So we can give that punk Neil deGrasse Tyson, a run for his money cause he’s like in the top 10 and I wanna be there too.

The other thing that you can do to help the show, is subscribe on Facebook. We have a new supporter function that we’re beta testing with Facebook, it’s like $4.99 a month and you get early releases, you get exclusive live conversations with me where we can talk about stuff that then will make its way to the main page. It helps us pay for all this and grow the show and give you a voice. Very, very helpful to us.

The third thing I wanna say is, if you’ve noticed my face, I went to the dermatologist. The other day you guys saw Dr. H.L Greenberg and he’s like hey, after the show he’s like, I can burn off a few other things with, you know, the hyfrecator here, and I’m like sure go for it bro. Now I look like I was in a meth lab explosion. Which is still an upgrade people for my face. So I apologize if I look a little ratty.

Now I’m gonna introduce someone who does not look or sound or think ratty. This is Dr. Lois Ramondetta. She is professor of gynecologic oncology, at MD Anderson Cancer Center in Houston, Texas. That place is the bomb Tom Hinueber. And by the way, recently ranked number one for cancer care in the US She and I met at the Texas Medical Association’s, big shindig where I keynoted and she came up afterwards and is like, here are all the things that we have in common about how we think. And I said you need to come on our show to talk about women’s cancer issues, HPV, palliative medicine and oncology, and the intersection of those things and yoga. Who knew? Dr. Ramondetta thank you for coming

– Thank you for letting me be here.

– Man so your flight just got in and you came direct from the airport.

– [Lois] Directly.

– And you look fantastic.

– [Lois] Thank you.

– [ZDoggMD] How, why is it that I look like a meth lab explosion survivor?

– I didn’t go to the dermatologist yesterday.

– You know it’s interesting I hadn’t been to the dermatologist all my life and I go and I’m like wow and he’s like well you have this and you have this and you have this and you’ve made a few trips around the sun. And I’m like are you calling me old?

– [Lois] Yeah you are in Las Vegas.

– That’s true, the sun, I’ve been here for six years and it’s really, Houston is no walk in the park either.

– [Lois] No, it’s not.

– [ZDoggMD] Yeah, yeah, yeah. See where your–

– We have humidity though.

– That’s true. I find it protective actually.

– [Lois] Yes, exactly.

– So you are passionate about women’s health, about palliative medicine, about obviously cancer as a gynecologic oncologist. You’re a surgeon so you treat these cancers but you also treat obviously, the woman who’s suffering from this And what I found so fascinating about you is that you’re one of those rare oncologists who also does end-of-life really well. I want to get into that a little later because I want to start by talking about HPV, which is a passion of yours, the human papilloma virus.

– [Lois] Yes, big passion.

– We talked about it with Patrick Ha, ENT, head–

– [Lois] That’s a great interview.

– And we’re mostly talking about head and neck stuff. We avoided the lady parts and I’ll tell you why. Quite frankly they frighten me. So the chance to have a world expert really–

– It’s great to ask questions.

– Yeah, yeah and I have many questions. I have many, many questions and number one is, every, you know lots of women since they’re young have heard about I should go get my annual physical and my Pap and to get screened for cervical cancer.

– [Lois] Right.

– But the the way that we do that and the guidelines for doing that have changed. Can we start–

– Just the other day.

– Yeah tell me about this.

– Well, so they changed a couple years ago and everybody was on the same page, and we’re still kind of on the same page but we don’t need to do any screening before you turn 21.

– It’s a, was that different before.

– [Lois] It used to be 18.

– 18.

– [Lois] Yeah so now it’s 21.

– Yeah.

– And at 21 you can start getting screened every three years.

– [ZDoggMD] So it’s not every it’s not the annual.

– No more annuals and there are quite a few people who are still doing annuals.

– [ZDoggMD] Right.

– And the risk of that is that you over-treat.

– So tell me about that because I’ve done shows about the annual physical exam, and over-treatment resulting from that. What can happen to women, who get an annual pelvic every year?

– First of all, a pelvic is not a little thing. It is an invasive exam and it’s not something that people look forward to on a regular basis.

– What?

– Yeah.

– I was convinced like.

– No no they don’t like that. And so spacing out your pelvic exam to every three years is a nice thing. This doesn’t mean that you see the doctor every three years. You should still see the doctor. It’s just that your pelvic exam and your Pap smear doesn’t need to be any more often than every three years. And a Pap smear’s just that little brush that they put on top of the cervix and then put it either on a slide or in a container of fluid and then the pathologist looks at it for abnormal looking cells. The problem is, is that the most likely time to be exposed to HPV is during those early years. One-third to one, one-quarter to one-third of women and men in that age group have been exposed and have HPV. And so, if you find it, you’re gonna wanna do something about it. But the good news is most of the time it goes away on its own especially during those years.

– So even early on it can spontaneously regress.

– [Lois] Exactly. Most of the time it does.

– Here’s a question so how are you catching this? Do you have to get to first base, second base, third base, what base–

– Just about any base.

– [ZDoggMD] Any base?

– Any base.

– Can you be in the stands watching the game with popcorn?

– I have to think about that. It depends. I have to think about that. It might involve kissing during the popcorn.

– [ZDoggMD] Okay, so actual contact.

– Yeah intimate contact. And that can be described in a lot of different ways. Touching. Touching hands in intimate areas, bringing it to your mouth, putting it back down. All sorts of ways that you can experiment when you’re young and be exposed.

– And there’s multiple strands.

– [Lois] Intercourse is not required.

– So you don’t need to get to third, is third base intercourse? Tom Hinueber, is third base intercourse?

– [Tom] Hell yes, Z.

– Okay, we have an

– okay, yeah, no.

– Affirmative on that.

– No, yeah no definitely not.

– Yeah I don’t know.

– First base.

– Yeah I was, I studied to get into medical school therefore there was no base at all. I think I may still be HPV free, just naturally.

– Well actually probably not.

– That’s true.

– The odds are not in your favor for that.

– What is the overall incidence then.

– [Lois] 80 to 90% of us are gonna have HPV, at some point in our life.

– So people who are like, well my kid’s not gonna have sex, they’re not going to get HPV, so therefore they’re not going to get vaccinated.

– That’s kind of a strange wish for your kid. I mean you kind of hope at some point that your kid would have an intimate relationship with somebody.

– That’s kinda true, that’s kind of true. I’m, I, you know, yeah it’s still tough for me to wrap my head around with two–

– [Lois] Someday.

– Teenage girls coming up in the world, but yes absolutely. So the question than is, if everyone’s gonna, you know there’s certain strains of HPV that’ll be, that will tend to cause cancer. We vaccinate against some of those strains.

– [Lois] Nine of em.

– Nine of them, but yet we are, chronically under vaccinated in this country.

– Yeah we did just get those numbers too and we are making progress. Last year 60% of adolescents had gotten their first dose and this year it’s 65%.

– That’s great.

– So it’s approaching that 80-ish percent that we really need to get herd immunity from.

– And herd immunity is when enough people are vaccinated, the virus just doesn’t have a place to hide anymore–

– [Lois] Exactly, it used to be cough, cough, herd immunity. This is a little bit more intimate herd immunity but yeah.

– Hmm, we got to think of a good sexy name for intimate herd immunity. Yeah let me, I’m gonna, pa conjugate on that,

– Come up with that one. Let me know.

– Yes, I’ll work on that. I’ll let ya, I’ll send ya a message. So the this idea that then, vaccinating can lower the incidence of those precancerous and cancerous lesions of the cervix. We’ve talked about head and neck stuff, anal, and other things that can cause. But you’re really specialized in the women parts, and in particular the cervix. Are there other types of cervical cancer that can happen that are not HPV related?

– Not so much. I mean you can have metastatic disease, to the cervix. There are some very high-risk type, like neuroendocrine carcinoma of the cervix which is not HPV related. But almost every other type is HPV related.

– Got it, got it, so really by by immunizing, you’re lowering the risk.

– [Lois] Absolutely.

– Do you ever see an opportunity that we could immunize everybody such that we wouldn’t have to do screening anymore or do you think they’re always gonna have to do screening?

– So right now we’re vaccinating, but we are vaccinating with the HPV 9. But years ago we were doing only the HPV 4 and then there was a 2, I don’t know if you remember those. But HPV 16 and 18 has been protected against through all three of those vaccines. And those are the ones that you and Dr. Ha talked about, most likely to cause oral pharyngeal cancer as well as cervix cancer. But then there’s a bunch of other types that can cause cancer. Now we’re protecting against those. So we’ve moved the protection rate for cervix cancer from about 70% with those early vaccines to about 85% with the newer vaccine, but that still leaves–

– Still not perfect.

– Still not perfect.

– Still not perfect. So do not be a falsely lulled into thinking, I don’t need to get that–

– [Lois] Absolutely still need to get screened.

– So now let’s go back to the screening. Every three years starting at age 21.

– [Lois] Uh hmm, just the Pap.

– [ZDoggMD] Just the Pap.

– We don’t test for HPV, we just assume they all have it.

– [ZDoggMD] Got it.

– And they’re gonna get rid of it, in most cases. It’s the persistent HPV infection that’s the problem. So when we turned 30, we start looking for that HPV infection. Now if you have an abnormal Pap during those first few years, you will get tested.

– God, okay, okay, okay, okay, let me rewind that cause this is, I’m learning something here. So the reason we don’t do HPV testing in the 20s, from 21 to 29 is because we just assume they have it. Even if they were vaccinated, with the earlier vaccine, right? So we just assume they have it so we go ahead and do the Pap looking for abnormal cells and precancerous lesions. If they have the precancerous lesions, then we would consider doing HPV–

– And remember that we’re only at 65% for that first dose this year. We were 60 percent last year, and the year before that we were in the 50s. And for those, for the percentage that finished the vaccine series and are completely protected, we’re still only at 48%. And that’s, and boys are actually doing a little bit, starting to do a little bit better. Nobody seems to be worried about vaccinating the boys as much as they seem to be worried about vaccinating girls.

– And I want to come back to that is that, cause the vaccine reluctance with HPV vaccine is obscene.

– It is really strained.

– It’s based on insanity, bad PR and just fear.

– And confusion.

– Confusion?

– Confusion, and lack of knowledge, because again, you guys probably talked about this in your interview but we really didn’t even understand the oral pharyngeal connection until recently. So the original marketing was to girls and to OBgyns who were vaccinating too late anyway. The kids were already exposed. Then it was to pediatricians then it was, oh yeah let’s vaccinate the boys, so they can protect the girls. And they were like oh wait a minute, the fastest-growing cancer is oral pharyngeal cancer, the tonsil in the back of the tongue. So we need to vaccinate the boys to protect themselves because they’re the ones that are getting it.

– Yeah, you know and actually Great Britain actually recently, their NHS, actually approved vaccinations for boys and girls I think. And covered it which is a big deal because as a socialized medical system, they are very interested in cost-effectiveness. they found it to be cost-effective to create the herd immunity. And, and so–

– Well the treatment is unbelievable that people have to go through for both of those cancers. The things that they, they’re on the opposite sides of the body, the oral pharynx and the cervix, but the treatment involves weeks of radiation, horrible effects to quality of life. Definitely change for your, you think intimacy will be affected then it will absolutely be affected after chemo and radiation or a radical hysterectomy. And so protecting or preventing these kind of cancers is the most important thing. And I see all sorts of cancers but this one we actually know what caused it and we know how to prevent it, we know how to screen for it. So when I see someone dying from this, it’s it’s just a tragedy in multitudes.

– Can I get angry for a second?

– [Lois] Yeah.

– So–

– [Lois] I’m angry.

– Yeah. There are nurses, nurses

– Head that this morning.

– There are nurses in my own tribe, who say, I’m with you on vaccinations Zdogg, I’m with you on measles, mumps, and all that but I just don’t feel good about the HPV vaccine. I think we need more years of data, and I’ve seen lots of bad terrible side effects, and young girls being paralyzed and this and that. And they don’t look at the da, primary data. They don’t look at the meta-analyses that looked at the efficacy and the safety of this, which is unparalleled, unparalleled.

– Yes, a regular vaccine.

– Over a decade of experience with this and they have the nerve to tell patients this, and I’ll tell you why this makes me angry because like you said, we have seen women die of these preventable cancers.

– It’s not uncommon.

– It’s not uncommon and here’s the thing you’re a surgeon, part of your your livelihood is treating these cancers. You want to see them gone.

– Oh I don’t ever, wanna see them again, yeah. So there’s a real hope that we could, eliminate HPV related cancers, starting with cervix, if we get the vaccination rates up and we continue to screen.

– Let’s talk more about screening because otherwise I’ll just get so angry about the prevention, by the way, by the way, here’s a funny thing, so my daughter is 10, my oldest daughter. She came to me the other day because she watches all my videos she saw More than Warts the video, she was in it!

– That you know, that’s one of the main reasons I’m here because I have been a fan since that video.

– So we did that version with me and Devin, then I did a new version live with me and my daughter. And she saw it and she’s like what is this HPV thing? And I go, well it can cause cancer of your lady parts, if you don’t get the vaccine and you’re not careful this in that. And she said okay so when can I get the vaccine and I’m like well you’re ten, typically eleven.

– [Lois] You could give it to her now.

– We could do it now. She is game to do it now. I even told her it’s a series of three.

– Two.

– It’s two?

– Yes, cause if you do it on time, it’s only two. Six months apart.

– I’ll tell you what as soon as I go home, I’m gonna schedule with her pediatrician, and we’ll do it.

– Well the nice thing about doing it now is that when she turns 11 and she needs to get the Tdap and the meningococcal vaccine.

– [ZDoggMD] Do it all.

– She’s got all three and then she’s done.

– [ZDoggMD] Yep.

– Rather than getting all three and knowing she has to come back for another. This way you kinda–

– So again and that’s the thing, multiple do it all at once and you know we use something called buzzy. Which is, it’s another doctor, Amy Baxter developed this device. It’s a cold vibration device. It’s a neuromodulator so it goes right above where you give the injection

– My daughter what I love that.

– Oh we have Emmitt, we have live video that we posted on Facebook of both my daughters getting flu vacs with Buzzy and they didn’t feel a thing. In fact they laughed.

– I wouldn’t, I’m sad to show you a picture of my daughter getting her HPV vaccine. I told her to smile and look proud so I could show the picture and it’s not showable.

– You know what though, yeah, and the thing is there’s so much of fear, you know what I think, I think a lot of people’s unconscious were conditioned, we have fear of needles, we have fear these things and that, really when we’re looking for confirmation bias to feed our unconscious sort of fear of this, we go, well see here was a lady in Japan who was paralyzed, here was a woman, a video. And of course those images have nothing to do with the vaccine, they’re just correlated. And so this idea that then you can generate all this fear and people then grasp onto it and go, I’m not gonna get this life-saving, life-changing vaccine.

– I think the other thing that’s concerning is the kind of lack of confidence in our own system to find harm, and that to not recognize that we don’t want there to be harm to people. And so I usually use that example of the oral rotavirus from years ago and how when that came out, although there, there was no specific concern related to intussusception, it is out about eight or nine months, an intussusception, or when the bowels collapse on each other in the infants occurred, it was pulled from the market immediately, within within six to eight months I believe it was. and so the HPV vaccine has now been out twelve years. We have millions of evidence, pieces of data related to this and no definite correlation with anything other than that it hurts a little bit. That any adolescent who gets a vaccine has been all hyped up about it, might faint. If they hit their head, that might get reported as a complication.

– Sync-able event with head trauma, right?

– Right. So make sure they don’t fall. Maybe maybe a little fever, maybe a little bit.

– Yeah.

– Sometimes.

– Minimal, yeah. So really not much. And yet potentially life-saving. Now, going back to the screening so at age, from 30 to 65, what are we doing?

– So you have a couple of options and that’s where we, it’s like Starbucks. You shouldn’t have too many options, you should just have a couple, will get things better.

– I like a venti latte HPV with a side of Pap, I said soy Pap please. Yeah soy Pap is gross by the way, you don’t want that, just go full fat Pap.

– So there’s a, so up until recently you could do HPV co-testing with a Pap and HPV DNA testing, every five years.

– [ZDoggMD] So the HPV DNA tests on the cells from the Pap?

– Uh hmm.

– [ZDoggMD] Got it.

– Or the continued to every three years Pap smear. And now you can do just HPV testing every five years.

– And what are you testing with HPV? It’s the high-risk HPV strains. Are you testing cells or what are you testing?

– You’re testing for the DNA. oh yeah you’re testing for the DNA.

– Sorry, sorry, you’re testing for the DNA but what’s your tissue sample?

– You’re still doing it, it’s the same thing.

– [ZDoggMD] Still doing the pelvic, yeah.

– Yeah, normally when you do the co-test, it’s a little swab and it’s not a separate biopsy, or anything like that. It’s just a swab on the cervix, put it into the solution, send it off to the lab. They can look at both the cells and the HPV by doing that. Now we’re just not collecting the cell information, unless of course the HPV comes back high-risk. In which case you then need to move on to your next step.

– Got it, and what, and that next step is actually–

– [Lois] Colposcopy.

– Colposcopy, described colposcopy for people like Tom and Logan, who will faint when they hear about this.

– Yeah so um, so in addition to the speculum, which is a lovely device placed into the vagina, to look at the cervix, you then have a microscope that you move in close to the speculum and you look at the cervix. Now the way that we were able to really detect abnormal looking cells is by using essentially vinegar. It’s a dilute acetic acid solution. And you put it on the cervix and then–

– [ZDoggMD] And it doesn’t hurt or anything?

– Well, um, it doesn’t but if you have any excoriation, itching, anything like that, it does burn. I mean if you put vinegar–

– [ZDoggMD] If you put vinegar on anything.

– On anything, it’ll hurt. It’s like a lemon. So yes it can burn a little bit. And then you put on the cervix and it makes the abnormal cells look more white. There’s also other things that you look for. There’s a whole vocabulary that we look for. I’m sure you remember this.

– See the white. Yeah I remember this.

– See the white, acetic acid that turns it white. We also use words like mosaicism or we talk about the little cells look like cobblestoning. And that’s really from new blood vessel growth from neoplasia and so it looks a little bit unusual. and then sometimes you see new blood vessels on end, we call that punctation. And so–

– And those are signs of–

– [Lois] Pre-cancer.

– Got it.

– So over, so once you’ve been exposed to HPV, most people it goes away, in about 3 to 5 years, in a small portion of people you develop pre-cancers. And that’s where you get these overgrowth of these abnormal cells. And as long as it doesn’t go through the basement membrane of the epithelium, then it stays in as a pre cancer. And you can resect it with we use something called leap. We use something called cones, and you take out a portion of the cervix and that’s where over-treatment becomes an issue. Because if you do that a couple of times, you can really shorten the cervix, not to mention it’s a procedure that you can bleed from, it’s unlikely but it can happen. But you can short the cervix and potentially increase preterm birth.

– Interesting, so there’s it’s not, totally a harmless screening thing? Like any screening.

– Well definitely, I would say a derm screen is a lot less invasive, well not always.

– Look at my face, look, this is invasive.

– I’m saying it’s different. It’s not as invasive as a pelvic exam. And then biopsies hurt. So when you look at the cervix before you move on to the cone biopsy, you’ve usually done some biopsies to prove that it’s a precancer and then you do the resection.

– So, so,

– So you don’t wanna do that if you don’t have to do that.

– And you touched on over-treatment, over-screening. This is why maybe every year is not a great idea. This is why maybe after 65, what are they saying?

– So if you’ve had normal Paps and no new risk factors, like let’s say you were recently divorced and you’re out on the dating scene again. then you, and you’ve had three normals, and no long history of any pre-cancers. Then you can stop screening. That’s a decision you should have with your primary doctor. Cause everybody’s situation is a little different.

– It’s interesting cause you know a lot, there’s been a lot of talk of, as the boomers are retiring, they’re getting jiggy with it in the nursing homes. And meaning um–

– Yeah I’m not sure I know what that means.

– I not sure I know what that means, Dr. Ramondetta. No, they’re being sexually active–

– [Lois] Oh I’ve got it.

– Yeah with strangers.

– Yes, I’ve heard about that.

– In the nursing home, which first of all sign me up for that nursing home. Second–

– Why do you think sexually transmitted diseases are on the rise, in nursing homes?

– That’s right. So they’re getting syphilis, gonorrhea, herpes. The question is, is HPV, different strains of HPV, are they pose, these are unvaccinated adults. If you know, is that going to change our thinking of screening in, say a nursing home population, kind of like–

– So that’s interesting. So number one I think I mentioned that we believe that it takes at least three to five years to develop a pre cancer and then another probably about 10 years. In fact some of the early studies looking at HPV DNA said that if you’re HPV DNA positive, the chance of you getting a cancer within the next ten years is incredibly low. That’s why it’s five years. And we’re actually being able conservative. So if you’re HPV negative, you’re not going to develop an HPV cancer within the next five years.

– Got it, got it. And with the, so if your if your uterus has been removed, you’ve had a hysterectomy and the cervix has been taken and it’s it wasn’t for cervical cancer.

– Or dysplasia.

– Or dysplasia. There’s no reason to continue to screen.

– No, that’s correct.

– Right cause yeah.

– Yes, um, that would be like one of those unindicated tests that bite you later, yeah because you don’t know what to do with that. We don’t know what to do with an abnormal, what do we do with HPV in the vagina? We actually have no idea what that means.

– Right, right, right, so–

– It might mean increases, it’s like what you and Dr. Ha were talking about, you can swab the mouth for HPV but we don’t know what that means.

– [ZDoggMD] I’m glad you actually watched my interview.

– I did watch your whole interview, it was great.

– I’m very moved. Well you know what’s great, is now, to talk about it from the female care perspective is so important because that’s the vast majority of the effect that we can have with HPV. Although boys should be vaccinated as well as we talked about. But I think this idea then, that so, you get the screening right, the new guidelines, are there based on what? US Preventive task force?

– Yes.

– Right. Are, is there disagreement between the different entities?

– Not as many people have jumped on with the primary HPV testing yet. Although it is an acceptable option. It’s not, you know, most, ACOG still recommends co-testing. And in fact, I recommend co-testing. Many patients are still getting every three years cytology screens only after age 30. And I’m not exactly sure why their doctors haven’t converted over to the co test. To me that is, that’s the gold standard right now. And yes HPV testing on its own would also be good.

– Got it. How long have you been treating cancer in women?

– [Lois] I finished my training in 2000.

– And so since–

– Started my training in 1997, finished it in 2000. And yeah since then.

– So since then.

– I’ve been working at MD Anderson ever since, but I have had a job working at the county hospital for 17 of those years.

– [ZDoggMD] Which, which hospital’s that?

– LBJ.

– LBJ. Lyndon Baines Johnson.

– Wow so you’re taken care of, obviously a different social economic–

– Uninsured or low insured patients, who, you know that’s that’s one of the really fascinating things about the HPV disease, the the makeup of the men who are getting oral pharynx cancer, are usually white, heterosexual, upper-middle class men where cervix cancer has always been a disease of the underinsured because it’s all related to screening. So, let, if you get screened you might still have it but you can get it removed before it becomes a cancer. Whereas I was seeing patients presenting, they’re not even eligible for surgery. They’re only eligible for radiation, which can take about eight weeks to finish. So it was really upsetting and it was a regular thing. In fact the numbers for us are about, four thousand women die yearly in the U.S. from cervix cancer. God I felt like they were all there. And I think honestly a lot of that is because many of these patients are visiting the US. Definitely in the Texas area. And so they may not actually be even recorded in the end.

– Oh wow, so do you think there’s a component of you know, we talk a lot about discrepancies in gender, in terms of treatment. Doctors don’t take women’s pain seriously, they maybe aren’t taking different complaints, heart attack, those kind of things. Do you think there’s a gender discrepancy here, in terms of screening or do you think it’s more socio-economic issue?

– Well are you talking about screening for oral pharynx versus–

– Let’s just compare and say.

– We just don’t know, the epidemiology of the oral pharynx.

– Oh yeah it’s tough because you’re comparing apples and oranges because men don’t have a cervix, right? But, I assume anyways, although I sometimes wonder with Logan because he’s complicated. But the–

– He must be special.

– He’s very special, yeah. The, the idea that, you know, especially since in the older days it was obstetrics gynecology was a male-dominated profession. But now we’re starting to see a change. Do you think that’s actually gonna lead to better care for a women, or do you think it’s not gonna have a big effect?

– You know I, I think it’s about the person. I think that the gender of the physician, I think that you, you can have a great physician that’s a female or a male. It’s really about how they want to listen to the person. It doesn’t matter what gender you are necessarily. I suppose a first-hand experience of some things may be helpful, but man I’ve met some wonderfully, compassionate male gynecologic oncologist. So I don’t know if I would–

– [ZDoggMD] And we, you know we would–

– The screening is really about the socioeconomic status. It’s the fact that, it goes so far back. I mean to me it goes to elementary school, really understanding how to take care of yourself. You know, like we don’t really teach people how to take care of themselves. How to be their own self-advocate, how to know that I’m going to have to do cancer screenings, and then repeat it like from an elementary school education to a middle middle school education, to a college education, on this is self-care. This is what you need to do for self-care. And so you get out there and you don’t even know how to navigate a system, much less that you even needed to go to this system. Lots of women that I’ve seen with cervix cancer in the lower socioeconomic status, didn’t know that they needed Pap smears after they had a baby. Like they, their first Pap smear was when they were 40, because they had bleeding and it’s a cervix cancer and they hadn’t had babies, and it hadn’t been since they had a baby. And, and it blows my mind and I’m not sure at what point, it’s always so hard to decide whether it’s the patient, who didn’t take the opportunity or society who didn’t help the patient out, you know. It’s, it’s just such a complicated thing.

– And this is across the board with all disease management now, you know. There’s so this–

– [Lois] Where does responsibility lie.

– There’s social determinants, there’s government, there’s personal responsibility where they all intersect.

– [Lois] Those crummy school lunches, they never learned how to eat healthy.

– Tell me about it, and then you have TV, which is really good at teaching us to get a big gulp. And to really want that newest Barbie doll thing.

– [Lois] Have you seen some of the hamburgers on there?

– Do they look delicious?

– Well I don’t eat meat so–

– [ZDoggMD] Aw, are you a vegetarian or a vegan.

– I eat fish.

– [ZDoggMD] Okay so you’re a pescetarian.

– Yes.

– See I know my terminology. Well so this idea then that we’re hyper-educating people on how to behave badly, but not really doing a great job with like you said self-care. Now here’s a question so–

– In many ways.

– In so many, in every way. You you’re at MD Anderson, which is an amazing institution for taking care of tertiary care stuff. So that means you see a lot of referrals. Walk me through what that’s like, what’s your, like what are these referrals like because these are people who have obviously cancer, of of the nature that you’re going to take care of, so women’s cancers. And they’re coming to you, just walk me through some of that, because I think a lot of our audience, even though they’re in medicine. If they got cancer they wouldn’t know what to do. When do you get a second opinion, when you get a third opinion? What does it mean to go to a top Cancer Center? And what are you often telling people?

– So, I’m so glad you asked that because medicine changing so fast right now. So when I first started working at MD Anderson, most people came from local surrounding areas. And over the last few years they definitely have become more of a referral center. We still see local patients but we also see a lot of people come in for second opinions. And it’s really changed things. I am somebody who really has always wanted to cover Edmonton Symptom Assessment Scale when the patient comes in. Or to really get to know the patient and to kind of walk that journey with them. And now my clinics are very often filled with patients who have flown in, maybe even arrived that day, and know they’re going to spend a few days at MD Anderson to get a second opinion. They have Cancer Care ongoing in other hospitals and they are looking for potential clinical trials, or just maybe to check that they’re getting the right treatment. What’s really crazy is that I still have the same amount of time to see this person. And and I want to be able to get to know them, but I may never meet them again. And I was trying to really find that time in those visits but there’s so much material to get through, their prior tumor histories, their prior cancer histories, what kind of side effects did they have from their treatment? Then now the whole new part is the genomic testing and what genetic abnormalities does their tumor have, or do they have, that might make them eligible for certain kind of trials. Or even if they were eligible? My other role is to talk to about, if that’s really the way they want to spend the rest of their life. Do they want to uproot their family and move here from another state for a period of time, to be on a clinical trial? Is it worth their time, what kind of side effects could they expect? And they’ll have only a few days to make, to really, to get all that done. They’ll come and see me maybe on a Wednesday, they’ll have their CAT scan on Thursday, they will maybe see another referral person on Friday, I’d love to squeeze in an integrative medicine visit, if they have time and then they usually fly home. And I’ll call them when I get their genomic results three weeks later. So it’s a, it’s really strange, and that some of the patients are in great health. And they really are there to be aggressive, they’re willing to move, they may have a lot of time left, they may want to be able to come and try something that might really have an amazing response. There are other patients who maybe just needed to feel that peace of mind that they’ve tried everything. And that they didn’t give up before they’ve tried everything. So they got their second opinion and maybe my discussion is more like, you know you have a lot of symptoms, I really think that our primary effort right now should be to eliminate or at least reduce your symptoms, to give you the best quality of life with your family. And to make sure that you’ve you have an informed decision about where you’re going to spend the rest of your time. And almost every time I need to ask, do you have a medical power of attorney? And, and then that’s usually a lead-in question to, have you ever talked about a living will? And that can be a really hard conversation with someone who just flew in to meet you for their second opinion.

– Okay so several things, I’m talking to an oncologist, a gynecologic oncologist. I never hear a lot of oncologists talk about these things. They are the hammer and the patient is the nail, and the joke is why do they put nails in coffins? To keep the oncologists out. So they, I know.

– [Lois] I’ve never heard that.

– So and and the thing is, in towns like this, where it’s a community oncology, there isn’t a big academic presence. It is, it’s treat, treat, treat, treat, treat. Not have the tough discussions. You’re having the tough discussions in a way where, it’s very, it’s very difficult, because they’re flying in and they’re flying out. You don’t have a long-term relationship but you’re still doing it. To me that’s the essential heart of what the oncologist is. Is being able to treat but also–

– Well most of us who went into gyn-oncology, and I’m not saying we’re that different, but we are one of the few oncology fields that does both surgery and chemotherapy. And most of us went to this field through OB-Gyn because we wanted to be involved in the care of the whole patient. And we want to walk that journey from diagnosis to whatever that leads to. I think at least in my area, most of us have these conversations. It is becoming more difficult because the the number of new opportunities to treat patients is growing so fast, with immunotherapy, checkpoint inhibitors, anti-angiogenesis drugs. It’s almost like, you could give drugs until there’s nothing else to give. Forgetting what gives meaning to your life or at least having the patient think about those things, I think could potentially lead to burnout for the physician as well as lost time for the patient.

– I mean I considered a kind of moral injury, we’ve talked about this on the show. That burnout is a moral injury. It’s when we feel that we’re not doing for someone else what we’re supposed to be, because we’re torn in different directions. And I think, I think in oncology it must be so acute because there is, there’s the family pushing to make sure you don’t give up your fighting and we’re gonna go to MD Anderson, and we’re gonna make sure. Which it, that to me is beautiful, that people could come there and get also a sense of, if it is in that position, in a sense of closure. I talked to this wonderful doctor who looked me in the eye, who held my hand, and said you you’ve done everything you can do, now let’s really focus on your symptoms. And just hearing that can release the burden of, I have to fight this using this and this and this. Instead of I have to fight these symptoms and be comfortable and be with my family.

– I’d like to give you a very generic example, I’ll change some things about it, but one of those visits was with the person, who overall her performance status looked okay to me, but went ahead and ordered the things that we wanted to order including a CAT scan, which was done the next day. And the day after I saw the results of it, and it was overwhelming amount of cancer, and I called the family because she was supposed to have an appointment with the targeted therapy department later that day. And I said I don’t normally do this, but I really don’t think that it’s worth her time, to go to that appointment. And I really think that from what you said and the what she’s been feeling, I ended up talking to a family member, that she should go home. And I think she was relieved to hear that and the week after, I got an email from that person, who thanked me because they went home, and she died two days later. And she said you know what, had we not gone home on that day, we might not have made it. She had two days of saying goodbye to people and it was just the most beautiful thing. And she sent me a picture and it was just, it made my day.

– What a gift.

– Yeah, it was a gift.

– What a gift. Yeah I, you know and it’s interesting, Lois, because we met after the gig that I did and there was something about you because you talked about palliative care, you talked with just this, you know, you get mobbed after those things and the brief interaction we had I was like, this person is special because I think, there’s something about that manner of being with people, being able to listen being able to say this is not about me, this is not about medicine. This is about you.

– Life.

– It’s about life. And I, you know a related thought to that, is the men, the husbands or the female partners of your patients, how do you work with them or what’s your experience with that side of things?

– That’s interesting. Like I try to make sure I’ve, the patient is my primary responsibility, but it is definitely important for the patient’s support system to be involved and in fact not just from a physical sense but also for their well-being. And there’s actually, our integrative medicine person Lorenzo Cohen, just wrote a book with his wife. And that is the primary aspect of anticancer care that they talk about, is your social well-being. And the people around you to support you. Where it comes into play in the clinic, is it’s not unusual to have a family member look at me and say so what’s her prognosis, and I’ll look at the patient and say, is this something that you want to know and most often they’ll say, well sometimes they say yes, but many times you’re like, no you can talk to them about that afterwards, I don’t want to know exactly how much time I have, you can give me an estimate but, and we’re not great at that anyways you know, we’re, we get it wrong a lot of the time. That said it’s nice to know that you have an incurable cancer and there’s been multiple studies that have shown that patients who are getting palliative chemo, don’t actually know that they’re getting palliative chemo. And on a note that reminds me of your TMA lecture, when you talk about doctor and patient satisfaction. There was a great study a few years ago that looked at lung and colon cancer patients that were getting palliative chemo. And they asked them if they knew they were getting it, the majority of them didn’t know. What was interesting about it is those patients who didn’t know, had better satisfaction with their physicians than those who did. Which adds into this whole ethical concept of, you know, it’s like telling a patient that they’re overweight. I’m telling a patient that they die, doesn’t always, that they’re gonna die, is not necessarily a satisfaction winner and so how do you talk to the patient and their family in a way that maintains hope for whatever meaning that they’re going to have in their, that they could have in their life and that they can still do, and not make it be a downer.

– You know and to me this is one of the central premises of oncology, and any care, because you know I give terminal diagnosis. You know and it may not be cancer, it may be that you are terminal congestive heart failure, and that all the data says you’re gonna die in the next four to six months. And you’re right, you tell people in a, is the best way you can but your Press Ganey score becomes negative because that is hitting up against a wall of denial, that’s so powerful. And that wall may be all that’s holding them together, at that point. And it may certainly be a wall that they’ve built because they feel their family would fall apart. And it gets so complicated, it’s so unique.

– [Lois] Especially when you don’t have a lot of time.

– When you don’t have time cause then you’re like, well what do I do with–

– Or a relationship. Cause this is not necessarily a one time conversation.

– How can it be, how can it be? So you either flying in or flying out, but what they really need is that, so my whole advocacy piece has been, the primary care Doc should help to be the glue. But you know obviously a lot of times, you’ll hand off to an oncologist. But you need at least one person who’s there tying the pieces, and who’s there for you who’s saying, this is, I’m gonna speak truth to you. And this is what it is. And maybe there’s you know a nephrologist here who wants to dialyze you, and a pulmonologist who wants to drain that effusion. But I’m telling you this is the big picture and if you’re planning for your daughter and you’re planning for this. This is how you should think about it maybe. Or let’s talk about that.

– And that’s true for oncologist too because we have such great palliative care services, that sometimes oncologists, as you said, in fact that’s why I got interested in this when I did my fellowship. There were many different and through my life, I’ve met many different gyn-oncologist who approached death differently. And that’s a whole fascinating discussion Cause really to me it’s always been about, how comfortable you are with your own death. And, and whether or not you feel comfortable having these kind of and also your communication skills. Do you know the SPIKES protocol or do you know things like that. But I was so fascinated by the way some people would continue chemotherapy, longer periods of time, versus some who were just great at having that conversation early on. And I said, I did a survey early on and asked people about that. And what was really cool is before computers, and I still have all these papers, it was a written survey, people turned it over and wrote on the back. and just were interested in gyn-oncologists, interested in talking about how you come up with these. And there’s a whole theory about this called, you may know about it, terror management theory.

– [ZDoggMD] I don’t know this.

– Where death anxiety, where

– Teach me about this.

– Well I think it goes from a prior philosopher, whose name is eluding me right now, but Sheldon Solomon is one of the ones who’s written a lot about it. And it’s essentially that, how connected you are with your own death or how even being told about a death situation, like now, would affect, maybe even a care decision that I make for a patient later. Or a policeman might make in a judgment for someone else. So it’d be interesting to, to look at those things.

– I have no doubt this is the case. You know it’s interesting cause I recently, listened to Michael Pollan’s audiobook, How to Change your Mind.

– I’m listening to that on audiobook right now. That is fascinating.

– It is fascinating for people who don’t know, this book is about Michael Pollan, who had never really done psychedelics properly. LSD, psilocybin, DMT, these drugs, MDMA, different, slightly different class. He explored, went on this really travelog of exploring the new research on how those drugs, through inhibiting our sort of default mode network and all the inhibitory neurons that cause us to shut things down, opens us up to the experience of losing the self in the ego, and effectively dying. It’s a kind of a death, and experiencing what exists beyond that and coming back and going, that’s okay.

– Or potentially seeing things in a whole new way, I guess with awe.

– [ZDoggMD] With awe as–

– Or potential terror.

– Or terror. So and again, set, and setting and how you need a guide,

– [Lois] It has fascinating–

– Fascinating, cause in the 60s everyone just dropped acid, and a bunch of them freaked out and had horrible experiences, duh.

– Did you get to the part about, I think they were talking about Silicon Valley doing–

– [ZDoggMD] Micro dosing, yeah, So Silicon Valley–

– You gotta wonder about some of those video games, like where they come up with those ideas.

– So people like Steve Jobs would go up to engineers and shake them by the by the shirt and be like have you done acid yet. You need to do acid. So he was a big psychedelic proponent. And and the idea then again and I’ve tried psychedelics in college, and I’ll tell you, yes they do that, the problem is without a guide, you can have a horrible,

– I have to say I haven’t.

– Well you know it’s interesting, because in oncology, that’s where Michael Pollan talks a lot about the research, there was a story of a guy in his book who had biliary cancer and was dying and ended up to high dose psilocybin guided experience. had the experience of ego death, confronting his own death, confronting his tumor, seeing the loved ones in his life from a 30,000 foot integrative view. He came back and he continued to do chemo and all that but he when he was ready to transition to hospice, he was in an inpatient hospice and his life had changed so much, that people would come to his room, because he was giving off this aura of just equanimity and love. And he had seen things from a different perspective.

– I think this might be our intro into yoga only because–

– Perfect.

– Because I would say I had, so I turned 50 last year.

– Congratulation.

– Thank you.

– I thought about 35.

– Thank you so much. And I did a number of things that involved a puppy, but it also involved me doing a three week yoga retreat to become 200 hour yoga teacher. And the reason I’m mentioning this now is because spending three weeks, on a beach, in Panama, with nothing around except healthy food and the other people that were doing this retreat, put us into this almost unreal state of mind. When I came home, it’s almost, it was so unreal because we were so high, on this experience and the equanimity of it, and being able to conquer everything, that I really did see things in a whole new life. And and on a very small scale, on a really, on a yoga experience, I get I like to do Baptiste Style Power Yoga. It exhausts you to the point that, when you’re in shavasana, that you almost have that sense of oneness, that is different. So I’m not saying I’ve had a psychedelic experience, but there are ways to get there and you know that’s what I feel with the cancer patients. I’m gonna go back for a second, but one of our clinical trials instead of looking at did we shrink the tumor by 20%, and oh my god that’s a partial response, that’s great. What if we also had a secondary endpoint, that said achievement of serenity or achievement of peace of mind or something along those lines that was really relevant to that person. And I’ve looked at that. It’s really hard to figure out how to design a trial like that. But wouldn’t it be great.

– But okay first of all that–

– Maybe it involves psychedelics.

– You know, actually, so since I, there’s so much in what you said, that I think resonates deeply with my own experience with this. So absolutely attaining these states of mind, do not require drugs, and in fact, Yogi’s and meditators have been doing it for millennia. I’ve had meditative experiences where it is that transcendent–

– Yeah, you’re regular meditator.

– Yeah, I’m a regular meditator, an hour a day, we’ve talked about on the show. And it’s it’s grown over six years. It is work. It is work and it’s practice and it’s recondition–

– Self-forgiveness.

– Self-forgiveness is piece of it, equanimity, accepting the present moment. There’s a lot of stuff that that goes into it but there are the states that you can achieve, and psychedelics are like strapping yourself to a rocket. And you know you’re gonna get somewhere, it may not be the right place, but you’re, definitely it’s gonna happen. With meditation with yoga it means, it’s more like getting in a boat and hoisting a little sail and trying to grow that sail and trying to guide it. You’ll get there maybe but you’ve gotta work at it, you’ve gotta be patient. But it may be a more gentle and forgiving, and reproducible and scalable way to do it. This idea of studying this in patient populations, first of all the fact that I’m talking, to a world-class oncologist about this, is a sign that there is hope in the universe. Because I know there’s a lot of people who like to throw out one or the other. No, no, no, it’s oncology, it’s chemotherapy, it’s this, it’s surgery, period. All the other stuff is nonsense woo. Then there are the woo-woo guys that are like, no, it’s about, bro we can meditate this tumor away and baking soda man and like a vegan diet. How about this, find what works for you, do not throw out the chemotherapy and the stuff,

– [Lois] Right, hand-in-hand.

– Mind-body connection is crucial, so yoga–

– [Lois] You also mentioned placebo effect which I don’t really like that word because it makes it sound like it’s not real.

– Oh, it’s the realest,

– But we know depression is real.

– thing in the world.

– And we know depression can change your outcomes for cancer. Why can’t the opposite? So–

– Absolutely and you can have a nocebo effect which is the negative version. And so to me actually placebo, and I agree, I think it’s a wrong term. It’s a mind-body construct. Because the mind and the body in yoga you experience this, in Vipassana meditation you experience this, it’s really just one thing. The mind and the body are just a kind of a feel of awareness.

– It’s being mindful which is required during end-of-life conversations. It’s about listening.

– And see the thing about mindful, even the word is so charged with BS administrator talk now, but the true meaning of that word, I don’t know if you got to this part in the book, in Pollan’s book, but he talks about platitudes and okay so, people who have these psychedelic experiences and meditators and Yogi’s, they come back and they come to the rest of the world, and they turn to the camera and they go, God is love, everything is one, we need to just love each other. And people look at them like so how high were you? Or what kind of hippie BS is this? The thing about platitudes is, they they are the simplest distillation of what is an awe-inspiring, ineffable, indescribable experience, of the true nature of things. And to come back and say God is love, is the best that the human monkey mind can do to explain something that’s transcendent. And I think it’s the same with what we’re talking about, mindfulness is a word but what it really means is, being there now in the present moment and aware that you’re aware of it. And using that in a way to relieve suffering.

– Right, to maybe even, you know, it is your gateway into empathy. And I was trying to think about this because my friend and I used to use, spirituality was a big word. And it still is for spirituality and medicine and what does that actually mean because people automatically go to religion. But it doesn’t mean that. It means what we’re talking about right now, which is about having a connection with the patient, as two human beings in addition to one who has maybe more medical knowledge than the other. And listening and understanding where they’re coming from and the fear that they’re having. And maybe both of you being a little scared at the same time. With one maybe hopefully guiding the other one as best they can. I find, and this may be why I ended up doing the yoga teacher, I’m in the middle of my 300 hour training now and I teach a class at 6:00 a.m. Monday mornings. that’s the time they gave me at MD Anderson.

– [ZDoggMD] Of course.

– Yeah it works for me, but I have to tell you, it is one of the most rewarding experiences of all because on my regular basis, I am having those conversations that we talked about. But in my class, the other day, I like to give a little lavender massage at the end, I saw tears and it and I knew they weren’t sad tears, they were they were kind of the tears of wholeness. And anyway, it’s one of the most rewarding experiences for me

– You know it’s interesting cause again there will be people watching this, they’ll be like, these two hippies are talking crap. The truth is–

– [Lois] We can talk about cancer treatment too.

– Oh, no, no, no, no to me, to me and I think you and I agree, like this is the central premise of being a healer. It means being present in that way, recognizing those tears as something good and special. and a sign of an opening, right. And I think that’s what it is and I think whether it’s yoga, whether it’s meditation, whether it’s guided psychedelics, whether it’s just sitting in a room with someone and being there when they’re having the worst day, or month, or year, a couple years of their life. That’s why I think what you do is such a deep gift, and you see it, I think a lot of people get buried in the burnout of it.

– I have a lot of it now. There’s so much of it because it just keeps, and I think also the volume of knowledge that’s happening at this exponential level for doctors. In addition to the need to see more patients, there’s all of these new targeted therapies that we need to not only remember to give but to look for the targets, as well as to know the new side-effects. It’s very complicated.

– This is why I think AI, as much as we hate it, is actually going to help us to be better doctors, cause then we get to do this and the AI is like don’t forget this and this and this.

– [Lois] Right, the protocol says do this.

– Exactly.

– [Lois] Now we can sit.

– Now we can sit and talk and that’s wonderful. It’s almost like having a scribe. What was the EHR like for you guys going live at MD Anderson.

– I think most people heard about it, it didn’t go over, all that well.

– It made national news.

– It made national news and I’m still learning there’s some great things about it. You can definitely follow trends easier and still working in a county system for many years, that didn’t have one, trying to find that paper chart.

– Yeah, that’s brutal, right.

– Or their bracket, their genetic diagnosis which is on a sheet of paper sent in by someone else, this is something else. So communication is much better. That said, as you talked about in your Team-A lecture, you know very often you’ll find yourself looking at the screen instead of looking at the patient. And it’s really nice to bring them into it, like the way you guys set up your clinic to have the screen so that you can show the patient pictures if they want to see their tumor. I just think that it’s, it’s hard that, to remember to have that time to get to know them a little bit and whether or not that’s necessary, I don’t know but for avoiding burnout and finding meaningful meaningfulness in life, is probably really, really important.

– There’s a huge chasm between being there with your patient and a 99235 level five whatever. Right and I think if we can start to bridge that, and we will I think we’re in a transition period, this health 2.0, we’ll optimize for it, it’ll suck, people will get confused and think it’s the goalposts. But those, those like yourself see actually the shore we’re trying to row to, will use these tools to get us there faster and then we’ll transcend them. So that’s what I hope. And man what a real pleasure talk about this stuff.

– [Lois] It’s fun.

– This is the stuff that gets me up in the morning. You know, HPV is crucial important cancer–

– [Lois] Right remember how many cancers it causes.

– It causes a bunch, right? Cervical, anal, oral–

– Penile.

– Penile.

– Tonsillar, vuvlovaginal.

– Tonsillar.

– [Lois] We see three of those.

– We can, we think we can prevent a lot of these with the HPV vaccine, with the screening, which we talked about the new guidelines for. Thank you for educating me on that. We talked about colposcopy, and different more intense screening and the danger of over screening and over-treatment. We talked about being with our patients and end-of-life, and its intersection with oncology. We talked,

– We could talk a little bit.

– Oh and–

– It’s 10 years so it’s nice.

– This, so tell me about, you brought me this book, let me see if I can, there it is, The Light Within and it says here–

– I am advertising a little only because it’s 10 years ago that we published it. And Deb died more than 10 years ago. Deb was an ovarian cancer patient at MD Anderson.

– [ZDoggMD] She’s your co-author on this.

– She’s my co-author, she was a World Religions professor at UC Santa Barbara, and a PhD. And her ovarian cancer came on early in her life she never got to write a book as a PhD. This was something that she wanted to do. So for the last, I’m thinking, six years or so of her life, we, we became friends. And we would write to each other, and we also found reasons to write in France, and in Turkey and in Santa Barbara, in Texas. And what we did is we finished it while she was on hospice. And the way it’s written is that my text is normal, and hers is in italics. And her husband helped me finish publishing it and her daughter Abby is working now in New York, with kids of moms and dads who have cancer. And she’s just an incredible person. Deb and I really were trying to get out what was spirituality between patients and doctors. And we did a couple lectures together. She was just a fantastic person, and again it was ten years ago. What I’m trying to do now is make up, a playlist for the book. Because I somebody else did that, and I thought was a great idea. So I asked her daughter. And her daughter said Bob Dylan’s, You Got to Serve Someone cause mom said that’s true. So that’s that’s kind of where we left it now.

– This, I can’t believe you did this a decade ago.

– [Lois] I know and it’s it actually is reflected as a decade ago I think I’ve grown a lot since then and become more mindful and hope to continue to grow because that’s what it’s all about.

– What a wonderful thing, what a real pleasure talking to you. Dr. Lois Ramondetta, she is professor of gynecologic oncology at the MD Anderson Cancer Center in Houston. A tremendous human being, a tremendous doctor. She taught me a lot today and I hope you guys got something out of this. If you did do me a favor, hit subscribe on the podcast, review it, become a subscriber and definitely check, is it on Amazon?

– It’s on Amazon, very cheap.

– Very cheap. How do patients find you if they want to get a referral or a second or a third opinion?

– Just to contact MD Anderson, the gynecologic oncology department.

– Excellent.

– It’s new patients.

– So we’ll get links for that and we’ll put it in the web post.

– It was a pleasure talking to you because of what I really appreciate is how you are educating in in new ways. Because the the new world is about music and books and video clips, and stories and maybe Darth Vader. And and you’re getting really good information out there to the public. And I think it’s important and that’s why I’m here.

– Your $5 is in the mail. Thank you for that, those kind words. Dr. Lois Ramondetta, thank you again for everything. Have a safe travels home and Zpack, we out. Peace.