Breast Cancer Network of Strength


“Chemo-Brain,  Fatigue and Other Side Effect of Breast Cancer Treatment”

This transcript features Dr. Lillian Nail, the Rawlinson Distinguished Professor of Nursing in the School of Nursing and a member of the Knight Cancer Institute at Oregon Health and Science University in Portland, Oregon. Since the early 1980s, she has studied the experiences of people undergoing cancer treatment, including their experiences with treatment side effects and the impact of treatment on their day-to-day lives. She is best known for her efforts to make cancer treatment related fatigue visible and to develop strategies for preventing and managing it. A four time cancer survivor including two breast cancers, Dr. Nail is an engaging speaker who combines her knowledge of the science, personal experience and humor to provide practical advice about dealing with the side-effects of breast cancer treatment.

February 18, 2009

Breast Cancer Network of Strength ShareRing Network 2/18/09 7:00 PM CT Arline Kallick: Thank you. Hello everyone and welcome to the Breast Cancer Network of Strength Sharing Network national teleconference. Our call will begin with tonight’s speaker, Dr. Lillian Nail. Dr. Nail is the Rawlinson Distinguished Professor of Nursing in the School of Nursing and a member of the Knight Cancer Institute at Oregon Health and Science University in Portland, Oregon. Since the early 1980s, she has studied the experiences of people undergoing cancer treatment, including their experiences with treatment side effects and the impact of treatment on their day-to-day lives. She is best known for her efforts to make cancer treatment related fatigue visible and to develop strategies for preventing and managing it. A four time cancer survivor including two breast cancers, Dr. Nail is an engaging speaker who combines her knowledge of the science, personal experience and humor to provide practical advice about dealing with the side-effects of breast cancer treatment.

Our topic tonight is “Chemo brain, Fatigue and Other Side Effects of Breast Cancer Treatment.” The presentation will be followed by a question and answer session and end with small group discussions. We realize it’s difficult to answer everyone’s question in a one-hour teleconference. If your question doesn’t get presented during the question and answer portion or the group discussion, please contact the Network of Strength hotline at 800-221-2141. When presenting a question to Dr. Nail, please be courteous to other callers by keeping your question brief and realize it isn’t a private consultation. A transcript of each call is available at our website one week following the call. Just visit our website at Recording of past calls are also available as podcasts through I-Tunes. You can also listen to sharing calls at We’re now ready to begin with tonight’s teleconference and we welcome to you Dr. Nail. You may begin.

Dr. Nail: It’s a pleasure to be here tonight and to have an opportunity to talk about the persistent or later effects of breast cancer treatment and I know there’s a lot of interest in these and I have, of course, a strong personal interest in these as well as a research interest. One of the ones that there’s a lot of debate about is the idea of chemo brain which people talk about as feeling like they can’t remember things very well, primarily short-term memory problems. They have trouble concentrating. They have trouble finding things or they have problems getting lost.

I’m one of those people who used to be able to find my way around without a map. I sort of always knew where I was and I remember the day that that stopped and I can tell you there was chemotherapy involved, and I now own a GPS device because of that. I’m certainly not as good at remembering people’s names as I used to be, and one of the challenges when you talk with people about this is they say well, you’re getting older. Well I know that, but having problems remembering things and having problems finding your way around and feeling more tired than you think you ought to, these are not inevitable effects of aging, and what we see in the research on cognitive changes in people who have had cancer treatment and most of these studies have been done with women who’ve had chemotherapy for breast cancer, is that the changes that people seem to experience are relatively small in terms of does this mean that you just are absolutely incapacitated and can’t do anything, no, but they are noticeable, especially to people who have had a fluent cognitive ability all their lives, you know when your memory is not as good as it used to be.

The other thing we see in studies is that the testing that’s done tends to be done in a very pure environment so there’s no distraction, and the times when people seem to have the most trouble like my problem finding my way around, are when there are distractions or when you’re in a very unfamiliar environment and you’re paying attention to a lot of things at once. I think the researcher who’s been probably most involved in this, one of several, is Christine Meyers at MD Anderson Cancer Center, and she actually published a paper with the title “Chemo Brain is Real” to talk to her colleagues about what the actual experience was of the people she had tested and point out that their testing protocol might not mirror the actual situations where people were reporting the problem.

Then people always say well, okay, so other people have had this, but what should I do about it? And right now, we don’t have any tried and true ways of making these problems go away. The primary things that we suggest to people at t his point are to figure out when you’re most likely to have the problem. Is it when you’re more tired? And we always joke around in our research group and say we don’t know if thinking makes me feel tired or if being tired makes it harder to think, but certainly there’s a relationship there. Is it times when you’re in an unfamiliar environment that you have the most problem? Is it when there’s a lot of noise and confusion around you? So then you know to take it slow, to have a backup plan, to always have a map with you, to have a list of the things you wanted to make sure you did, to not depend on always remembering that new phone number but to write it down, and these are all compensatory activities that people use, and some of us kind of learn them by ourselves along the way and for others we get coached by people who say well that happened to me and this is what I did about it. I set timers to remember when I’m supposed to leave the house. I keep an extra copy of my calendar with me so that I’m not depending on my short-term memory for whether or not I have an appointment at 2:00 on Thursday and if so where it is. So it’s a little more structure and planning than I used to do.

One of the questions that people often ask is whether or not the computer-based programs that are being marketed to help people with their memory and with their thinking really do help and right now the neuropsychologists who have looked at those say that they help with that specific task. So you would get better at that particular computer game or exercise but that it doesn’t generalize to other situations. So most of us would like to generalize to other situations, so t hose right now don’t look like they’re being really helpful, but there may be other things that come along in the future that do generalize a bit better.

I’d like to go ahead and move on to fatigue. Right now we think about 10 percent of breast cancer survivors have moderate level fatigue that persists quite a long time beyond the end of treatment. Now one of the challenges with breast cancer treatment is when does treatment end, so I’m talking about the time period after radiation, after surgery, after chemotherapy, but it can be during the time when someone is taking a drug that manipulates hormones or some other drug for preventing metatheses or some other problem that’s associated with breast cancer. So within that group of people who seem to have persistent fatigue, we don’t know what exactly predicts it. Right now researchers are looking at a lot of different things and one of the ideas that people are quite interested in is whether or not the treatment somehow turns on or off an important gene in your body that has something to do with your immune response, so that your body is always producing more pro-inflammatory cytokines than it normally would.

Another question is whether or not this has something to do with the changes in estrogen levels in the brain and these are questions that people are looking at. They’re not easy to study. We’ve actually had an investigator in our research group who’s been working with mice and I always kind of hate to think of myself as a mouse but they are a useful model for these studies, and with the mice of course they don’t respond to interview questions about fatigue, so we have to look at how much they run. But in the animal models, we’re starting to get clues about what’s related to fatigue so that we can begin to understand the mechanisms and then start to explore those in people.

What we suggest to people who have long-term persistent fatigue is that they use a regular exercise program. That’s one of the things that’s been helpful in dealing with fatigue during treatment, and having better endurance and being stronger are things that it makes sense would be in general helpful to you afterward, but there is not a large body of research saying that it’s going to make a difference in long-term fatigue at this point. We also suggest to people some things that are very similar to the suggestions for chemo brain or cognitive changes and that’s that people be aware of when they feel most tired. Most people have a pattern that’s fairly typical on an average day. The most common is that it’s late afternoon when they feel the most tired, so for some of you, that would be right now, and then they can predict and organize their lives around that. So the time of day when you feel the most tired is probably not the time of day to engage in the most complex activity or to plan to have your exercise period or anything like that, and then we also suggest to people that they plan their activities so that they are doing the things that are rewarding to them and the things that only they can do and the things that they really want to do, and the reason we focus on the things that are rewarding is we find that when people are having a problem with fatigue, they tend to give up the things that they really enjoy the most and hang on to things they’ve done traditionally rather than delegating those that can go on to someone else.

For most of the people who have fatigue that’s in a pattern, they’re able to make some modifications in their lives so that they continue to lead a full life but they may have altered the way that they’re doing some things and some of them are really simple things like organizing your work space so the things that you use most frequently are closest to you and that your workplace is not really the type of thing that makes you more tired than you would need to be. My workplace right now I’m looking at it really needs desperate reorganization, but I haven’t got a professional organizer here yet.

Another thing that some people are trying now is to use drugs that make people more alert and these would be drugs that are in the general category of amphetamines. Some people have tried using methylphenidate which is Ritalin which is used for attention deficit-hyperactivity disorder as well and depending on the situation, drugs have been helpful in some studies and not in others. Some people use them on an individual basis. We’ve also suggested to people that they look closely at other potential causes of fatigue such as thyroid problems, and there are a lot of breast cancer survivors who are now on thyroid replacement which has been helpful for some of them. However, there’s not a systematic study looking at that yet.

There are lots of other side-effects of breast cancer treatment. One of the things that we’ve seen most recently with some of the aromatase inhibitor drugs is joint pain and stiffness and sometimes it’s quite severe, joint pain and stiffness. Again, nobody’s really sure why this is happening. There are very different rates of joint pain and joint stiffness reported across the different studies and there’s a lot of variation about whether or not people are told ahead of time that this is a potential side-effect of these medications, so we’ve met a lot of people who didn’t realize it might be the drug and have referred them back to their oncologist to really talk about that and evaluate it, sometimes changing the drug, sometimes stopping the drug for a short period of time and restarting it, and there are some people who decide that they do not wish to stay on the drug because of the side-effect. So people are doing studies now to really start to look at what’s happening, why is this happening and get better data on what the rates are with the different drugs and exactly what the nature of the joint problems are.

There are also some people who report some muscle pain after starting the aromatase inhibitors, and it’s also not clear exactly when after starting them these symptoms appear. We’ve seen them in people who have only recently started the drugs, and some of the studies say that they don’t really appear until a year after the drugs have been started, so there’s a lot of contradictory information out there right now so watch for more information on this and if you have a friend who starts one of the medications and suddenly starts to have joint symptoms, please encourage her to talk with her oncologist about it.

Another set of side-effects of breast cancer treatment that I understand that many of you are interested in are the post-menopausal symptoms including changes in sexual function, and there are a lot of different symptoms that are associated with changes in estrogen level and even if you were menopausal already, you may still experience changes in estrogen level that produce the symptoms. Of course the classic one is hot flashes and I will tell you that I once drove around all night in an air-conditioned car when I didn’t have an air-conditioned house because of hot flashes. This is not a good solution for having hot flashes, but it was the solution I ended up with that particular very hot night.

Hot flashes are difficult to control. People have all sorts of different patterns of them. We tend to think about them lasting for only a short period of time, but we have had patients in our practices here who have had them for many, many years after having their breast cancer treatment. There are lots of different strategies people use including avoiding things that they believe trigger them like chocolate and alcohol are common things that people say they feel are triggers for hot flashes. Some people use other dietary changes or supplements to deal with their hot flashes and every single one of these that’s been tested has mixed results. For some people they’re helpful. For others, they’re not. A lot of people have adopted the, what shall we call them, the cool max type of night shirts and pajamas that wick moisture away which are really, they’re quite comfortable to sleep in. I’ve used them, but we know that they don’t make the hot flash go away. They just help you with dealing with the feeling of the hot flash and the wetness.

Another challenge that comes about as one of the menopausal symptoms is vaginal dryness and this can be severe enough that people have trouble walking, and that’s a pretty bad quality of life effect when that kind of thing happens. There are a couple of different strategies for dealing with this. One is the use of topical estrogen. There are different schools of thought on this and it comes in different forms, including an ointment that you put on or put in with an applicator, and a ring that stays in place for 90 days that gives off a regular dose of the topical estrogen. Again, it’s controversial and different health care providers have different views about it. Some women with estrogen receptor negative breast cancer actually get some hormone replacement depending on what their symptoms are, again, extremely controversial, and different providers may or may not be accepting of it. There are other sorts of vaginal lubricants that are used and vaginal wetting agents. Some people have had good results from them, some not. Some people like one product over another. Others have different product preferences. People have described this as sort of a trial and error type of approach and you see what works for you.

When I used to have graduate students in oncology nursing, I would give them samples of these and send them out to try them all out just so they understood what the advantages and disadvantages of having these available were, and one of the problems is that some of them kind of leak out when you stand up which is really not a highly desirable effect. Others don’t leak as much and there, again, are individual differences in which ones people prefer.

Another problem that’s related to vaginal dryness is painful intercourse, and we usually refer people to a gynecologist who is a specialist in this area to really talk about what’s going to work best for them, what sort of wetting agent they should use, what their partner should use, things to avoid, and really have a very careful evaluation and discussion of what types of options are available for that person in that situation and it depends somewhat on what other co-morbid illnesses are as well.

Then with breast cancer treatment, we also have the possibility of lymphedema which in breast cancer appears as swelling in the arm and the hand on the side where the breast cancer was. Unfortunately, lymphedema has not been studied very well, although there are a number of research groups that are working on it now and a lot of interest especially since we’ve had more use of the sentinel node biopsy as part of initial breast cancer staging where the assumption going in was that this would make lymphedema a problem of the past, and everybody was really hopeful about that, but it turns out that even in people who have had only a sentinel node biopsy, some of them still get lymphedema. So the cause is not really clear. Some people say it’s surgery. Some people say it’s node surgery. Sometimes people say that it’s radiation therapy that does it. What we know right now is that between ten and 30 percent of women with breast cancer experience lymphedema at some time following the diagnosis of breast cancer. It’s very hard to predict who’s going to have it right away, who may have an isolated episode later. There are many different strategies that are suggested for preventing lymphedema. It’s important to know that most of those do not have a research base. Their best judgment from a long time ago and some of them are just sort of common sense things like you would want to avoid cutting your arm or hand to decrease the risk of infection and others like the old prohibition on repetitive motion that involves resistance, so any sort of weight lifting or work that involved resistance training are being questioned as possibly predisposing people now to lymph edema and weight training being possibly a way of preventing it or treating it, and these are questions that are being studied right now.

There are very few studies of weight training in breast cancer survivors that involve the arm on the side of the surgery and radiation, but the studies that have been done don’t show that it increases lymphedema in any way. Again, there are very few studies with small samples.

For people who do have lymphedema, the primary approaches to managing it have been compression and massage. One of the things that has made a difference is that for women who are overweight who lose weight who have lymph edema, the lymphedema tends to decrease in the majority of those women, and again, people think about a common sense explanation for why that might happen. We don’t really have a scientific explanation at the (inaudible) level of what’s happening there. So the thing that’s surprising to some women who’ve gone for years and years without having lymphedema and suddenly they wake up one morning and their arm and hand are swollen is, you know, what happened, why did this happen to me and at this point in time, we really don’t know. For some of those women, the lymphedema lasts for a brief period of time. They see a lymphedema therapist and it goes away. For others, it comes and goes for the rest of their lives, and for some, it responds a bit to treatment but it’s still there and they may end up using a compression garment over the long term. This is an area where we know that we can make a big difference in people’s lives if we had a really good way of preventing this from happening.

Other side-effects that people talk about over time, occasionally there’s someone who had pain in their chest wall as a result of surgery. For some of those women, it appears that they develop a syndrome that’s like fibromyalgia where there are soft tissue trigger points and we often refer them to see a rheumatology group which is folks who usually treat fibromyalgia because they’re the ones that are best equipped to make treatment recommendations for this type of syndrome. And then other things people are concerned about are things like body image. You don’t look the same as you used to. The body is a different shape or feeling like there’s a numb area as the result of surgery or strange sensations as a result of reconstruction. Again, not very much research on these things,– we don’t have a good characterization of what the pattern of numbness and tingling and changes might be. With the introduction of dose dense chemotherapy for breast cancer which introduced Taxol into the treatment of early stage breast cancer, we also have the question around the neurologic effects, specifically painful peripheral neuropathy and a numbness and tingling peripheral neuropathy that can come with Taxol and whether there will be people who have long-term numbness and tingling and difficulty holding on to things, you might drop things more frequently than you used to, especially if they’re slippery. You might have to compensate by watching more carefully where you put your feet if you trip and fall, though we don’t know if that’s going to end up being a long-term issue, and the other long-term issue that has arisen is that chemotherapy seems to accelerate bone loss in women who are susceptible to bone loss and the aromatase inhibitors also seem to accelerate bone loss, so dealing with strategies to prevent that including using disphophanates, drugs to prevent bone loss, calcium, exercise, all of those sorts of things, because when your bones are weak and you fall, then you fracture, and I think all of us know women who have fallen and broken a hip and all of the challenges that that poses and don’t want to be the person that that happens to.

The good news is it’s being studied now and the research on the disphosphanates is extremely promising because we’re also looking at it as potentially a way to prevent bone mesthaseses in addition to preventing fracture and osteoporosis.

And I think we’re ready for questions now.

Alexandra: My question is I’ve had breast cancer and I’m on Tamoxifen now and I was wondering of any of the symptoms in the vaginal area get better once the Tamoxifen is finished.

Dr. Nail: That is a great question. There are some people who say that those symptoms have gotten better once the Tamoxifen is finished. However, the action of Tamoxifen and the way it acts in tissues varies according to type of tissue and initially there was a belief that it wouldn’t cause the vaginal symptoms. However, there are lots of reports of it doing that. I don’t know of a long-term study that looks specifically at the vaginal symptoms.

Alexandra: Okay. Thank you.

Trish: Thank you so much for your comments tonight. This is very helpful to hear. I’m wondering is chemo brain reversible? When you’ve finished treatment, does your ability to concentrate and remember things improve?

Dr. Nail: That is a great question. Most of the people that we’ve studied during and immediately following treatment tell us it gets better, and some people feel like it’s completely gone. There are other people who say it’s still there but it’s not as severe as it was right at the time they completed treatment.

Trish: Okay. Thank you.

Suzanne: Hi. My question was also about the chemo brain. How long does chemo brain last?

Dr. Nail: So the question was how long does chemo brain last? There are many people who are now years out of treatment who tell us they feel like their short-term memory still never quite got back to where it was before, that it’s better than it was at the end of treatment.

Suzanne: And what drug is that caused from?

Dr. Nail: We don’t know which specific drug. They are always given in combination.

Suzanne: Okay. Thank you.

Don I’m particularly interested in the chemo brain. I wasn’t on chemo for my breast cancer, but is there a difference between – I mean, I’m interested in, say, meditation, yoga, these other modalities which have a physical part to it like exercise but there’s also the mental part of it. Has it ever been studied that people who practice that have less severe chemo brain or people who didn’t practice it before but did after they got chemo brain, that they get better quicker?

Dr. Nail: Another wonderful question. I haven’t seen any specific studies about the questions you asked. However, any activity that causes you to focus your attention like yoga and really be very systematic about all of the things you’re doing is the sort of thing that has been used when working with children and are interesting. Chemo brain arose from the problems we were seeing in children who got cancer treatment with their academic performance. So it’s the sort of thing that is a component of the interventions that have been used in helping these kids recover as much of their ability as they can in terms of dealing with school, dealing with homework and dealing with day-to-day life. So I wouldn’t be surprised if

anything that helps focus your attention would be useful and it’ also has been used in dealing with fatigue. There have been a couple of published yoga studies and also been used in dealing with lapses in attention in particular, but not necessarily in cancer patients but the lapses in attention.

Don: Thank you.

Marie: In older patients, I’m 73, this is a choice of quality of life, avoiding the side-effects of arimodex in my case, which caused me to have character personality trait changes as well as extreme fatigue. Is that a viable consideration for me?

Dr. Nail: Certainly everybody has unique concerns and it’s always an interesting question about, you know, what’s the best thing for me to be concerned about in this situation and what’s something that’s very low-risk for me. So that carrying out that conversation with your doctor and talking to people who are really experts on the drugs is an important thing to do when you’re trying to make a decision like that. Some of the challenges that people face with some of the aromitase inhibitors are things that appear quite early in the therapy.: So we’ve had a lot of people say well I’m going to try it and then see what happens. And then some people say okay, this isn’t working for me. I’m going to stop this drug.

Marie: Yes. That’s what I did.

Dr. Nail: And in some studies, it’s up to 25 percent of the people that were put on the drug who have stopped it.

Marie: I see.

Dr. Nail: It varies a lot from study to study.

Marie: I see. Well I thank you so much for all of your information. It’s a blessing to have people like you.

Dr. Nail: Thank you.

Mary: Yes. I’m on Tamoxifen and I had early breast cancer and I didn’t have to have chemo, but my children tell me that I have aged over ten years just since I’ve been on it and I haven’t been able to get off, get rid of thrush or yeast or whatever you want to call it, and no matter what they give me, I still have it, so I don’t know what to do.

Dr. Nail: This is an unusual situation. So people who have a long-term documented infection, we usually send them to see an infectious disease specialist. And depending on where the infection is located, it might be someone who’s an expert in oral, mouth infections or someone who’s an expert in vaginal infections. It just depends, but we usually when we have an infection that’s not responding to treatment, try to refer them to a specialist.

Mary: Okay. Thank you.

Dr. Nail: You’re welcome.

Barbara: Yes. I’m a second time breast cancer person and I had had chemotherapy this last time and got through that pretty well. Then I went on a clinical trial with both somara letrozole and Zometa and that seemed to be, and the fatigue, I’ve been on that a year and a half

now, it seems to be cumulative. I was so surprised at how tired I was at the very beginning and it just seems to be getting worse and worse and I don’t know if anybody else has had the combination with Zometa and the somara and if that has been the experience others have had. Thank you very much for your help on this.

Dr. Nail: Oh, you’re welcome and this is an interesting question. I have not dealt with anybody who’s had that combination. I would suggest checking with the folks who are, who run the trial that you’re in.

Barbara: Okay. They just sort of shrugged their shoulders.

Dr. Nail: They’re shrugging their shoulders. Oh great. Then possibly checking on the bulletin boards or the networking through the Network of Strength or one of the other groups and seeing if you can connect with any other people that are on that combination.

Barbara: Okay. It does seem to be – You know, because the people I know who are on somara alone don’t seem to be having near the problems that those of us or at least in my case I’m on both, and I’m giving serious thought to quitting the clinical trial because it is…

Dr. Nail: That would certainly be an appropriate option to consider.

Barbara: Thank you.

Jan: Hi. I have a question. I had breast cancer. I did not have chemo. I had radiation. I’m currently on Arimidex and I wanted to find out, I’ve been on it, it’ll be two years in May, and I wanted to find out if being as my stage of breast cancer was zero, if I still need to be

on it. I know my oncologist says he wants me on it, but the cost is a lot. I did get from the chronic disease fund, I did get on their plan for a year after my extra amount that was zero from surgery, so I ended up being zero last year, but now it’s costing me even in my co-pay with work, I still work full-time and some of the things you talked about with fatigue, I noticed too and the aches and pains of the hands and feet, things like that. I did have some arthritis before, but it seems like it’s intensified sometimes maybe because of the Arimidex, I’m not sure. I work at a Sam’s Club. It’s very cold where I work at the door, you know, checking receipts. I’m just wondering if I need to still be on the Arimidex seeing as I was almost two years on it now and I was a stage zero because in the Arimidex book from Astra-Zeneca, it did say stage zero may not need to be on the Arimidex at all. (Inaudible) out that shows, you know, some of these effects, side-effects, this, that and the other thing. I don’t know if I’m –

Dr. Nail: Well it’s a really fascinating question. There are several different approaches. Sometimes we suggest to people that they go back and ask their doctor exactly how much benefit would I get because that sometimes when it’s initially discussed, it seems like it’s an all or nothing It must be making a big difference (inaudible).

Jan: Like in the beginning I didn’t have any. Right.

Dr. Nail: Yeah. (Inaudible) quite a bit smaller than we think, and however the question about stage zero which is not where the drug has been tested to the best of my knowledge, is one where usually what I would personally suggest to somebody is that they check with their friends and get a second opinion from another oncologist.

Jan: Oh really? Oh, okay. So that would be a benefit, huh?

Dr. Nail: They perhaps see someone who has, is not the person who suggested it to you. You want to check with your insurance and see –if they need to pre-certify that or something, but certainly when it’s in stage zero, most authorities would say it’s controversial.

Jan: Oh really? Because they didn’t find it and her two negative and being that these things – In the beginning, I wasn’t going to even take it and then I thought well maybe he’s right, maybe I should take it. You know, and I did and I’ve been and now I’m having a lot of things, but then it isn’t – It’s not summertime, it’s winter, you know, where I live, and near the Northern Illinois border, and it’s cold, but I don’t know. I’m just curious as to after reading this in the Arimidex booklet that that was a possibility that I may not need it at all. I called their office the other day, mentioned it to them and she said well he’s had this discussion with you in the beginning. If you want to make an appointment to see him again in May, and they did suggest they had some samples there they could give me, so it would help me with the cost right now because I’m in between finding out how much I can, you know, if I can get on another program.

Arline Kallick: Excuse me. Thank you for calling. I think we’ve actually run out of time.

Jan: Oh, okay. Thank you.

Arline Kallick: I promised Dr. Nail that I would let her go about now, so before we go into the discussion groups, I really want to thank you, Dr. Nail, for your insightful, knowledgeable and excellent presentation regarding the many side effects of breast cancer treatment. I’m sure we could still all agree that even with the side effects, treatment is important and we’re thankful that treatment is available to us. Thank you very much for participating this evening.

Dr. Nail: Thank you all. It was great to have a chance to talk with you.