June 19, 2010 Workshop
I thought we had a good workshop yesterday. There were around 50 or so patients and their caregivers. The workshop lasted from 1:00pm to 4:00pm – I think it could have gone on longer but that was when we had to vacate our rented conference room. Many generous folks brought treats and goodies to eat during the break – thank you!
Below are the slides and comments from my presentation at the beginning of the Workshop. The discussion session that followed was very interesting, a lot of back and forth between the participants. In future workshops my preference would be to increase the time spent in the discussion sessions and drastically cut back on my opening remarks. Given our limited resources of manpower and funds, I do not think I can manage monthly workshops. Tentatively speaking, the next workshop will probably be in early August.
I want to point out that there are other CLL workshops you should be aware of. Diane MacKinnon hosts monthly workshops in the DC area. Click here for the details. I understand John Balan organizes regular workshops in the NJ and NY areas. You may want to contact him for the dates, venues etc.
Welcome. Thank you for coming to this first CLL Topics workshop.
Let me introduce our team. It should not take too long since there are only three of us. Most of you know me – at least by name. I am Chaya Venkat. I started this patient advocacy effort after my husband was diagnosed with CLL in the summer of 2001. Whatever we do right or wrong on our website or this workshop, the buck stops at my laptop. I take full responsibility for our content.
Please say hello to my daughter Radha. She is our webmaster, she is in charge of all things having to do with the website. My husband PC was our fist webmaster, editor and publisher. I am very proud that Radha chose to step into her father’s shoes when he passed away June of 2008. If he and she were not there to build and maintain the soapbox of CLL Topics and Updates, I would be mute, I would have no way of reaching any of you. The third person of our team is Peter Fortman, our treasurer and the best son-in-law in the whole wide world. He is the one who takes care of our finances, keeps track of the business issues, donations, taxes etc. That’s the size of our team. Unless you want to count Jasper, PC’s therapy dog. Jasper thinks she is the receptionist – she discharges her duties by barking loudly whenever my phone rings.
Let’s get started. This is a workshop, not a lecture. The idea is for you guys to set the agenda, decide what issues need to be addressed. But since this is the first workshop I thought I would get the conversation going with a short presentation. Feel free to ask questions or comment as we go along. In future we will solicit topics of discussion ahead of time from attendees.
What do we want from our doctors?
At first glance this seems to be a simple question. We want our doctors to take care of us, help us beat the odds and fight this disease. We want them to be smart, well informed, compassionate, and wise. We want them to give us answers to the many questions we have about what ails us.
But obviously things are not working out just right. There are unmet needs and confusion about our respective roles, given the level of frustration felt on both sides of the examination table. Things are changing rapidly in the health-care arena and no one is quite sure of the new rules of engagement. What we have here is a failure to communicate you might say. So, I thought I would start off our discussion with a few slides outlining what I think we want from our doctors. You may disagree with my point of view, you may want to add or subtract from this list. Speak up. The whole point of this and hopefully future workshops is to serve your needs, what you think is working right, what needs to be improved in your health-care as you face down this disease.
I want to reassure you, there is no recording of this conference. No one is taking notes, no one is taking down names of participants. I will put up my slides and these opening comments on the website – my privacy was shot a long time ago and I no longer worry about it. We take patient confidentiality very seriously and nothing you say here will be reported by us. You took the time out of your busy life to attend this workshop; it would be nice if you can share your thoughts on the workshop as a whole as well as the discussion session with the rest of our membership. I hope many of you will do that. But whether you choose to comment here or elsewhere, that is your decision.
We need a rock solid diagnosis.
Until quite recently, not much was known about CLL. Just a few short years ago CLL was just one more member in the family of non-Hodgkin’s lymphomas. Even more recently, even after CLL was split out as separate cancer, SLL was still part of the NHL family. Now the consensus is that CLL and SLL are the same thing, even though they may have slightly different ways of showing themselves. Our understanding of CLL and what makes it tick is increasing rapidly. With understanding comes the ability to fight it more effectively.
How can you fight an enemy you cannot name? There are too many B-cell cancers that can look like CLL to the untrained eye. Mantle cell lymphoma is one such kissing cousin. It is a more aggressive cancer, needs different therapy strategy and you are not well served if your CLL diagnosis is an error and you actually have MCL.
Today, given the level of access to modern diagnostic testing, there is no excuse for incorrect diagnosis in the vast majority of CLL cases. For most CLL patients, it is possible to get a dependable diagnosis of CLL with little more than a CBC (complete blood count) and a flow cytometry. Both are blood tests, both are pretty much automated by now, both are offered by all the major commercial testing labs. It should be slam dunk for your oncologist to order these tests, get the results and read the tea leaves for you in a matter of a week at most.
True, a small percentage of patients present with very atypical disease, where the diagnostic tea leaves are a little harder to read and these guys are best served by going to an expert center where they can do more advanced testing. SLLvariants of CLL may also pose a problem in early stages since SLL patients have the vast majority of their cancer cells tucked away in swollen lymph nodes or spleen, very little of the disease shows up in their blood. A blood test on early stage SLL will not be very useful. For these guys it may be necessary to do a lymph node biopsy and use the biopsy material for the diagnostic flow cytometry testing.
Watch out for the guy who orders unnecessary tests! I have often wondered why so many doctors order tests that are not really needed. In third world countries like India there is often a link between the doctor and the testing lab, with lucrative kickbacks for each patient the doctor sends to the testing lab. In this country the incentive for over-testing is probably not quite that obvious. Perhaps it is concern over potential lawsuits and doctors cover themselves by doing more tests than necessary. Or it may have to do with sheer laziness, not engaging brain before writing the prescription, practicing medicine by rote. It takes time, patience and years of experience to do a careful physical examination, poking around looking for swollen nodes and measuring the size of the spleen with nothing more than experienced fingers. It is far easier to tell the patient to go get a CT scan. Whatever the reason, there is an explosion of over-testing in this country. Please read our article on the risks and rewards of CT scans. Expensive medical procedures are not necessarily in your best interest. There is nothing that can be learned from biopsy material from a lymph node that cannot be learned from a simple blood test at the time of first diagnosis, not unless the patient is an SLL patient with all of the disease present in swollen lymph nodes and no trace of it in the blood. Everytime your doctor orders a test, it is a good idea to understand how it is actionable. What is the point of doing the test, how will it effect treatment decisions? Unless the testing is being done in the context of a clinical trial, there is no reason to test just to satisfy the curiosity of the doctor.
Our first local oncologist was not one that I would recommend to any other CLL patient. My husband PC went through a painful and completely unnecessary lymph node biopsy. He was also told to get an ultra sound and CT scan. This was just at diagnosis! Completely unnecessary, expensive, and exposing the patient to inherent risks of anesthesia and radiation. It really pi$$ed me off that with all these additional tests the local oncologist still got it wrong, PC was diagnosed with stage 4 non-Hodgkin’s lymphoma. It took a trip to M. D. Anderson before we got the story right. PC had Stage 1 CLL.
Prognosis at Diagnosis
The fact that you are here, that you are members of the CLL Topics community tells me one thing. You are not the ostrich variety of patient. You want to know, you want to have some control over your own healthcare, you believe knowledge is power. In other words, you are my kind of people.
Until recently, until patient advocacy groups and the more vocal patients began to raise a stink about it, majority of local oncologists called this disease “a good cancer to have” and that was the extent of prognosis information patients got at diagnosis. Calling CLL a good cancer is condescending and insensitive at best, downright wrong at worst.
I think feel-good clichés are inadequate when patients face an incurable cancer. True, some folks have a very indolent variety of CLL, may not need therapy for a long time. For them CLL does not significantly impact either quality or quantity of life. But for the rest of us chickens, CLL will impact your life, and the life of every one who loves you. Average life expectancy after CLL diagnosis – this is an average, your mileage may vary – was about 8 years. Was, because it has been going up with modern understanding of the disease, its complications and how best to treat it. That is the good news and we should all be aware of it, celebrate it.
Roughly a third of patients diagnosed with CLL will have very low keyed variety of the disease. These folks are in what we call “Bucket A” risk category and they will not need therapy for a long time, if ever, and they will not face much decrease in quality or quantity of life. Another third of patients will have middling disease, Bucket B. They will need therapy down the road. But chances are good that they will get decent remission and trundle along for quite a while without too much trouble. It is the last third of patients that will face the true wrath of this disease. These “Bucket C” patients often face therapy decisions very soon after diagnosis, they are most likely not to get long lasting or trouble free remissions. They will go through layers of salvage therapy, relapsing more and more quickly after each round of treatment. They face more infectious complications, pay a bigger penalty in terms of loss of quality of life. Telling these folks that they have a “good cancer” is adding insult to injury.
Under-treating an aggressive form of CLL can be a devastating mistake. Equally important, over-treating an indolent form of CLL with too aggressive chemotherapy regimens is like shooting yourself in the foot. I often use the analogy of a hornets’ nest, sleeping quietly in the sunshine. Why would you want to take a big stick and shake it up, get the critters all mad at you? That is the equivalent of over-treating an indolent form of CLL. Here is the take home message. It is next to impossible to make smart therapy choices until and unless you know what kind of CLL you have, your particular risk bucket. If you happen to draw the short straw and are in the high risk group, it is important to know that right up front. Fludarabine is probably the most commonly used chemotherapy drug in CLL. And it does not work in patients with the dreaded 17p deletion (FISH test). Why would you want all the toxicity and risk of adverse effects associated with single agent fludarabine therapy, if it is not even going to work for you? You might be better off using one of the chemo-immunotherapy combinations such as FCR, which have been shown to have more oomph in these high risk cases. And if you are a young patient with a lot of life left to live, you may want to think about a stem cell transplant down the road. See what I mean about knowledge being power?
Prognostic testing is not cheap, only some of the commercial labs offer full set of testing. Over the last decade a number of prognostic markers have been suggested. We reviewed the most promising prognostic candidates in our article “What type of CLL do you have”, way back in 2003. More recently, just in the last week or so, Dr. Terry Hamblin wrote for us with his take on where things stand today, what has withstood the test of time. Interestingly enough, he too picks the same list today as we did back in 2003.
So, what is the short list of prognostic tests? We are talking of FISH test, IgVH gene mutation status test, and flow cytometry to see if you are positive for CD38 and ZAP70. Beta-2-microglobulin (B2M) is measured by an inexpensive test. That’s the lot, that’s the list of prognostic indicators that will give you a good sense of the lay of the land. Each and every one of these is a blood test. But if you are a SLL variety with all of the disease in swollen lymph nodes and no trace of anything in the blood, obviously prognostic testing cannot be run on blood, it will need a bone marrow or lymph node biopsy to do these tests. It is also not possible to do blood tests for these prognostic markers if you are a very early stage patient with hardly any CLL cells in your blood, yet. Wait a bit until the disease has had a chance to become obvious in blood counts before getting the prognostic tests run.
Some HMOs balk at prognostic testing, for cost reasons. A small number of oncologists can’t see the point of all this new fangled stuff that was not mentioned back when they went to medical school couple of decades ago. A few don’t want to order the tests because they are not sure they know how to interpret the results. In each case, my advice to you is to try your powers of persuasion and negotiation. They say you can catch a lot more flies with honey than with vinegar, though I do not have personal track record on that front. When all else fails, there is always the tried and true remedy of voting with your feet and finding yourself a new doctor who is cool with modern approaches to treating CLL. Finding a new doctor is a stressful thing, and it may involve inconvenience in terms of longer travel time etc. But in the long run it is not to your advantage to be treated by a physician who does not have your confidence.
But I want to talk about doctors that do not believe you have a right to that information. A kind way of putting it is they don’t want you to worry your pretty little head about it, you are not smart enough or competent to understand how cancer prognosis is going to effect your life. My question to these guys is a simple one. Who elected them god? It is your body, your life. You may decide you do not want to know – and that is your right, your prerogative. But no one can or should be able to deny you access to information about your own diagnosis and prognosis, if you want to know. Hey, you may be every bit as dumb as your doctor thinks you are (not!)but you may have this spouse of kid that is a real genius and can sort all this stuff for you. Or you can read up about prognostic indicators at a credible patient advocacy site. How can your physician be presumptuous enough to make the decision about something as important as your access to your own medical information, after seeing you for a fifteen minute consultation? Last time I looked, not too many oncologists have advanced degrees in psychology. In any case, no reputable psychologist will make such a snap judgement call on his/her patients’ competence.
On the other side of the fence, I often hear complaints from doctors about unrealistic expectations some patients have. No one has a perfect crystal ball. No one can tell you with 100% surety how this disease going to behave in your particular case. Prognostic markers will give you some sense of the odds – how it may behave, how it behaved in statistically large samples of patients with similar prognostic profile. But statistics are just one way of handicapping the horse race. They cannot tell you for sure which horse is going to win, which one is going to stumble getting out of the starting gate. Holding your doctor accountable for guaranteed outcome of prognostic testing or therapy is both unrealistic and unfair. The best your physician can do for you is give you a good sense of the lay of the land, based on years of experience – and modern prognostic testing.
One last sobering note. CLL is still an incurable cancer. It still kills people. Age at diagnosis matters. Most young guys diagnosed with this disease will face huge decrease in their overall life expectancy as a result of this disease. Someone who is 85 and just diagnosed with CLL – especially if it is a low risk variety – the penalty in loss of life expectancy is vanishingly small. But for some one in his 40’s, a projection of average life expectancy of 10-12 years is a huge blow. Even the best and most knowledgeable doctor cannot change that fact. He can help you play the hand you have been dealt to best advantage, make sure you live as long as possible and with the best quality of life possible. He may guide you through a allogeneic stem cell transplant (“mini-allo” transplant) that may actually CURE you, get this monkey off your back once and for all. But when all is said and done, your physician too is another human being with no magic wand to make all this go away.
The well informed doctor
So let’s talk about a well informed doctor. What can he do for you? What can you expect reasonably from your oncologist, over and beyond an accurate diagnosis and your possible prognosis?
He can warn you of what to watch out for. He should warn you of the risk of secondary cancers. He should tell you about skin cancer, how it is much more likely to happen in immune compromised patients such as you, how it can be a lot more aggressive and dangerous for CLL patients. He can read you the riot act about avoiding excessive UV exposure. He should test you for vitamin D3 sufficiency, especially if you are good about avoiding sun / UV exposure like he told you to do. He should make sure you are on vitamin D3 (cholecalciferal) supplements if you are sub-par on this important vitamin.
He can tell you about pulmonary infections. How majority of CLL patients die of infections, especially pneumonia and other pulmonary infections. He can give you guidance on how to avoid getting infections, how to improve your odds of staying out of the hospital during flu season since you are not going to benefit all that much from flu shots. (But you should still get your flu shots, for whatever little good they may do you. It is even more important that everyone else in your family gets flu shots, so that you can get the benefit of “herd immunity”). He should warn you about the risk of shingles if you have been exposed to chicken pox in your younger days. He should make sure you are protected with prophylactic medication (famcyclovir, acyclovier etc) if you are a high risk patient, especially if you are going through T-cell depleting therapy using drugs such as fludarbine or Campath.
He can tell you that just because you got CLL, that does not mean you are now exempt from all the other stuff that go can go wrong for human beings getting on in life. You still need regular checkups for breast exams, prostate exams, colonoscopies etc. You still need to worry about being obese, about lack of exercise, about poor diet, stress, smoking etc. He will ask you about any over the counter medications you are taking, talk to you about the risks of “poly-pharmacy” – taking too many pills at the same time, without careful evaluation of how they may interact with each other. As a cancer patient, it is even more important that you hang on to your wallet and don’t buy a lot of snake oil stuff that can really hurt you in the long run. In other words, he will treat all of you, the whole person, not just your CLL.
He can say and do all these things, he can be a paragon of virtue and competence, and it will be of no use at all unless you have your ears and mind wide open to receive this good advice. If you are like most of us, stressed out and unable to concentrate when faced with a cancer diagnosis, if doctors’ offices send you into a trance where your brain stops working and you cannot remember a thing the Man said afterwards, make sure you take someone with you who can be your eyes and ears, someone who can take notes that you can refer to later, when you are calmer and more able to concentrate. Sometimes doctors are comfortable with you taking a tape recorder with you into the consultation, so you can record the conversation. But please be sure to ask permission before you record – it is common courtesy, and possibly the legal thing to do.
When Watch & Wait ends
Frustrating as W&W is to most patients, believe me it beats the alternative – by a mile. With the exception of a minority of CLL patients who have a truly “smoldering” variety of CLL, most patients will eventually reach a stage when they are going to need therapy to rollback the disease. That is when the hard work you did in selecting a good physician and building good interpersonal relationship with him/her is going to pay off, big time. The time to do the hard work is well ahead of time, not when you have reached a crisis point and need to react quickly. You know the parable of the ant and the grasshopper. Plan ahead.
This is a complicated disease with few slam dunk answers. Nothing is plain vanilla black and white, everything is a frustrating shade of grey; a matter of weighing risks against rewards. Sometimes none of the choices are particularly attractive, patients can get caught between the devil and the deep blue sea. It is your doctor’s job to explain your available options, clearly lay out the risks and rewards associated with each choice. Should you go with the tried and true “gold standard” or should you explore the road less travelled? What is likely to give you most bang for the buck? Are there good clinical trials that may offer you a chance of getting access to state-of-the-art drug technology, along with a nice bit of good karma for doing the altruistic thing for future generations of patients?
While they can lay out the options and explain the risks and rewards associated with each of them, most doctors have a preferred choice, the therapy that they think is the best option for you. Consensus decision making is not easy and our medical schools do not train doctors to be good at it. Should your doctor lay down the law, there is nothing left to discuss, it is his way or the highway? Most of us feel intimidated in situations like that. We have been conditioned to be respectful to the guy in the white coat. Surely he knows what is good for you?
But there is this little problem. You are the one with CLL, it is your body, your life, your family is the one that is going to be grievously hurt if you kick the bucket. You have far more skin in this game than your doctor. Surely that means you have some say in the decision making? Does your doctor have the listening skills and the ability to come up with a consensus plan that both he and you can agree on? How about the other side of the coin, the doctor that lets you get away with any silly thing you suggest, does not bother to correct your mis-conceptions? If he does not push back when you suggest wheat grass and juicing as an alternative to necessary FCR therapy, something is not working quite right in your relationship. This dynamic tension between listening to the patient’s preferences and needs, but fulfilling his role as the trained and experienced physician – it is possibly the most important thing to look for in your oncologist.
Once the decision is made, that is just the start of a complex process. Drug dosage details, scheduling, insurance issues, prophylactic medications that the patient needs to be told about – tons of things that need to be thought through and carefully communicated. If you are like me, detailed understanding of what is going to happen, some level of control over the process – this is necessary for sanity. Get into the habit of writing down stuff, filing information. Maintain a medial log, whatever it takes to capture all the information. Down the road you will be glad you did.
Every once in a while there is a news report about how many patients die in this country due to silly and avoidable errors made in hospitals. Wrong drug is given, the dosage is not right, they got the patient’s name mixed up, they cut off the left leg when it was the right arm that was supposed to be amputated – scary and needless errors. I believe things are getting better, most hospitals are introducing ways of checking and double checking stuff. All the same, when PC was going through therapy, I had a cheat sheet with me each time. I knew exactly what drug he was supposed to be getting, at what dosage, what precautions were to be in place, what pre-medications he should be on to reduce risk. This is something that patients’ find hard to do for themselves. CLL takes a lot of stuffing out of our guys, both emotionally and physically. If you are a patient going through therapy, it is a huge advantage to have your significant other there to hold your hand, watch out for the details, talk to the doctors and nurses, drive you home and make you your favorite comfort food with a large dollop of tender loving care.
Managing expectations is important. What does your doctor tell you about the possible results of the chosen therapy? Does he sugar-coat the potential risk factors, adverse effects, does he project the most rosy of all outcome scenarios? If he does, then his patients are sure to be disappointed down the road. An optimistic approach is necessary, but not condescending, over the top sugar coating of facts. Reality will set in, sooner or later, and the patient is left feeling like road kill that has been run over by an eighteen wheeler. Managing expectations is hard enough to do, and it becomes a lot harder if the patient is unwilling to listen or accept any reality check. In other words, the doctor has his share of responsibility in this two way communication, you have your share of responsibility as well. It works best when both you and your doctor are willing to participate in the process.
The Patient from hell
I get a lot of emails from patients anxious to tell me about their experiences at the hands of incompetent or insufferable doctors. I am willing to bet there are many more such stories that I never hear about, the patients involved are too shy to speak up, too intimidated, or no longer able to speak in their own defense because they are no longer living.
What might interest you is that I hear almost as many horror stories from my contacts among local oncologists and CLL experts. Each one has a favorite story to tell about the “Patient from hell”. Sometimes it is just a question of incompatible personalities. But more often it is a matter of unrealistic expectations.
With the best of intentions, even the most experienced doctor cannot save the life of a terminally ill patient. CLL is an incurable cancer. My phone book is full of numbers and email addresses of good friends who can no longer answer the phone, who have no use for email addresses in this world. Remember this mantra – doctors are human too – and you will not become the patient from hell. You will not expect your doctor to have god-like ability to control life and death, you will cut him some slack for having human emotions of tiredness, bad temper and frustration once in a while like everyone else. You will understand he too has his biases, his built in blind spots and prejudices, just like everyone else.
Can your doctor be your best buddy? No, he cannot be and you should not want him to be. Remember the old adage that no doctor should treat a member of his own family? There are plenty of good reasons for why that is so. Physicians need to maintain a clear head to make smart decisions. There is only so much emotional bandwidth each of us has, only so much grief we can handle at any given time without losing it. Would you want to be treated by a physician who has just lost his best buddy patient before he walked into your hospital room? Would you want him making critical life and death decisions with regard to your care, while he is on an emotional roller-coaster of grieving for his previous patient? Doctors who cannot maintain a certain amount of detachment soon burn out. Look for that kind of unconditional love and support from your family and your close friends – not your doctors. That is not their job, it is not their proper role.
I must confess, this is an area where I speak from some amount of personal experience. Patient advocates and nurses too face similar risk of burn out. By the very nature of our interaction with patients, we have to be emotionally closer. Clinical detachment that doctors can develop as a way of protecting themselves does not work as well for nurses – or patient advocates. For me it has been a constant struggle not to get in so deep that I cannot resurface to help the next patient that needs me. Sometimes it has been a touch-and-go. I have been doing this for a mere 7 years, most of my patients I know as online contacts. ICU nurses who put in long hours each and every work day, see their patients and their families up close and personal, and do it for all of their professional lives – these are the unsung heroes of our health-care system. The next time you come across a really good nurse, please remember to say thank you.
What is the role of patient advocacy?
If you broke your leg and went to the doctor, the process is a simple one. An x-ray will confirm the diagnosis, your leg gets put into a cast and you are given the usual instructions to stay off it for a few weeks. No big deal, some pain but not much angst. No need to call in the experts, unless there is something very unusual about the broken leg.
CLL is a very different situation. First, it is a complicated cancer in the sense that no two patients are exactly alike in their prognostics, symptoms and how they respond to therapy. Second, we are learning more and more about this disease as time goes by. The rate of change in our understanding of CLL is mind bending. It is next to impossible for most local oncologists to stay abreast of the latest cutting research being done at the expert centers.
Conscientious doctors depend on national meetings like the ASH (American Society of Hematologists) and ASCO (American Society of Clinical Oncology) to hear about the new developments. Continuing Medical Education (CME) programs are geared to help physicians stay sharp. Medical journals like “Blood” and “Journal of Clinical Oncology” provide excellent reading opportunities. All of these are necessary and important for your doctor to be up to speed on new developments.
But what happens if this downward trickle of potentially life-saving new information from the expert to the local guy slows down or stops altogether? Running a busy oncology practice is a full time job. What if your guy cuts a few corners when it comes to keeping up with his CME exams? That is where patient advocacy comes in. We are in the middle of this triangle of experts, local oncologists and patients. We have contacts with local health-care providers, we talk to all of the experts, and most importantly, we talk with the patients. We can teach you what you need to know, we can tell local guys what their patients need, we can help expert centers recruit patients for pivotal clinical trials. We can make the process work better by facilitating communication between all three stake-holders.
All this stuff is important. But there is one aspect of patient advocacy that takes first place in my head and my heart. Doctors and experts have plenty of support, lots of spokespersons looking out for their interests. Patients are often the “little people” overlooked in the process, no one invites them to a seat at the table, no one has their agenda at heart. That is my role. To speak for you when you cannot, listen for you at meetings to which you are not invited, warn you of things that can bite you personally in the backside – that is at the heart of what I try to do.
Several pharmaceutical company reps asked me if they could attend this workshop. The answer was a firm and unambiguous NO. This is a patient meeting, last thing you want is to listen to a bunch of salesmen. But down the road, I want to try and get local CLL experts to make guest appearances at future workshops. How does that grab you? Do you think that will be useful, or do you want to keep this strictly for patients and their families? Let me know.
Thanks for coming, thanks for your support that makes it all work.
Happy Father’s Day. And for “Harvey” and all the fathers who are no longer with us – we will not forget you.