[00:00:00] Dr. Diane: Chemotherapy - it's no picnic. In fact most times it just plain stinks. The good news is that there have been major improvements in medications that often alleviate so many of the side effects. You know, those that we see in movies, but it's not a walk in the park. So here it is team 'A Survivor's Guide to Chemotherapy.' Hello, I'm Dr. Diane Reidy-Lagunes from Memorial Sloan Kettering Cancer Center, and welcome to Cancer Straight Talk. We're bringing together national experts and patients fighting these diseases to have straightforward evidence-based conversations. Our mission is to educate and empower you and your family members to make the right decisions and live happier, healthier lives. For more information about the topics discussed here or to send your questions, please visit us mskcc.org/podcast.
Here's the deal; chemotherapies kill dividing cancer cells, shrink the cancer, and prevent it from growing and spreading. So often my patients ask, "With all the advances in medicine, why are we still using these poisons?" The reason is because it still works and it's still the most effective approach that leads to a cure. Today we have Elizabeth Cruz, a Nurse Leader at MSK and an RN for 16 years. Her role and passions are to educate patients about chemotherapy. She is going to run down everything you'll need to know to prepare for treatment. We also have a brave survivor, Stacey Peltz, [phonetic] [00:01:33] who has endured eight years of on and off treatment and has learned to live with ongoing chemotherapy. Stacey will tell us how to actually get through it. Now, having eight years of treatment is not typical for a patient, but her journey and story illustrates how cancer can turn into a chronic disease. Full disclosure, these are my people, my former nurse for the past 10 years and one of my dearest patients. They are also the very best people to talk to us about these topics because they're in it and on the frontlines. Thank you both and welcome to the show.
[00:02:03] Stacey: It’s a pleasure.
[00:02:03] Elizabeth: Thank you.
[00:02:04] Dr. Diane: Elizabeth, can you just share with us what -- a patient is about to starting chemo or meet you for the first time, I would imagine they're generally scared. What reactions and how do you approach that for the first time?
[00:02:15] Elizabeth: Oftentimes I go in the room with a warm smile and I try to make them comfortable. I try to address what's the most important thing I can answer for them today. And I introduce myself and tell them, “We are here to hold your hand every step of the way and to help you through this.” The most common question is, “How am I going to feel? How am I going to tolerate this? Am I going to be able to work? Am I going to be able to drive? Am I going to be able to take care of my kids?” And the answer is “Yes, for the most part, but we will give you tips on how to take care of that. We are your lifeline. We are here to support you and educate you on how to monitor and monitor side effects, and when you can't, you call us.” And that usually makes them feel better. I educate them on the side effects of the chemo, how to manage symptoms at home, because most of the patients and family and we as healthcare providers want them to be home to manage these side effects. And we encourage and we reassure them that not everybody has the same side effects. Stacey's side effects are not the same as Patient X, and we tell them that we will get them through it.
[00:03:28] Dr. Diane: When you talk about these side effects and managing, like I said before, I mean, sometimes you see these things in the movies, and you're like, “I'm going to be throwing up all day long and you're going to be in the bathroom.” So what is the reality of what to expect with some of these side effects that could be manageable, as you said?
[00:03:43] Elizabeth: And that's one of my intro lines: you should not be puking your brains out like in the movies. We really-
[00:03:48] Dr. Diane: Thou shall not do that.
[00:03:49] Elizabeth: No. And if that's going on, it's not normal.
[00:03:51] Dr. Diane: That is not okay.
[00:03:52] Elizabeth: Thankfully we have excellent antiemetics or antinausea medications that manage these side effects very well. And we have a variety of medications in the chemo unit that we provide intravenously, orally to patients. And we have other things that, you know, we can improve on if drug A doesn't work for you.
[00:04:14] Dr. Diane: So the important part is to sort of like even if you have queasy to take that medication that we're providing so that it doesn't accelerate and escalate, if you will, to feel nausea or vomiting.
[00:04:22] Elizabeth: Exactly.
[00:04:23] Dr. Diane: And they work. They do for the most part.
[00:04:24] Elizabeth: They do for the most part work and, you know, if drug A doesn't work we manage over the phone like you called me or portaled me and we tell you, “Okay, if this doesn't work, let's move on to step B, and I'll follow up with you tomorrow to see if it helped and do other management symptoms in terms of,” like not necessary medications, it could be meditation, it could be acupressure if we're talking about nausea and things like that.
[00:04:47] Dr. Diane: So we're going to get to them. We're going to ask Stacey again, who is our veteran here. But I'd like to share Stacey’s story because before diagnosis, Stacey's most pressing question was, “Why can't I eat ice cream anymore?” That question led to multiple tests and imaging that found tumors that were spread throughout her abdomen. She had to endure a surgery followed by chemotherapy, but unfortunately the cancer came back. And what we mean by that is that there were microscopic cells that were supposed to die off with the chemotherapy, but didn’t. During the next seven-year time span, Stacey endured two more intensive surgeries, was enrolled in a clinical trial with immunotherapy, and received essentially chemotherapy IV, oral, as well as directly into her abdominal cavity on and off again for almost seven years. So Stacey, we want to hear your story because you are clearly a warrior and a veteran, and you again illustrate how cancer can be turned into a chronic disease.
[00:05:38] Stacey: First of all, the first thing with Elizabeth, very important is not to go into that first meeting alone, because a lot of what you're hearing is just the noise in your head. You've just been diagnosed with cancer and you literally -- she says a lot of stuff and unless you're writing it down, which you shouldn't even be doing, you should be talking to her, somebody else should be there writing it down for you.
[00:05:55] Dr. Diane: Absolutely.
[00:05:56] Stacey: Absolutely. Because you remember nothing from that, often you remember nothing from the original diagnosis when the doctor is talking to you. But as far as being a veteran and a warrior, that was my goal in life, is to be a cancer veteran. Not really, but I guess it's my mission-
[0:06:09] Dr. Diane: You did not sign up for this.
[0:06:10] Stacey: You know, I was always in education. So I'm happy to be here educating people about chemo. I've inherited it and I'm going to do it, teach people the right way to do chemo. And it's basically with a sense of humor, I mean, you have to take it seriously obviously. But like Elizabeth said, not everything is so cut-and-dried, there are so many different medications for the side effects, and if they don't work, something else will work. And it's true, it's not like the movies, it's not like you're puking up your entire breakfast. Usually it's nothing more than a tablespoon and then you feel fine. It's the weirdest thing about nausea with chemo. One second you're nauseous, you throw up and you're done. You can have a full meal afterwards.
[00:06:44] Dr. Diane: How about that?
[00:06:45] Stacey: Yeah, you don't necessarily but you could.
[00:06:48] Dr. Diane: So for those that may be listening that they're about to embark on their first day of chemotherapy who are very early on in the journey, what do you recommend or suggest that they bring to the chemotherapy appointment with them?
[00:06:58] Stacey: Bring another person, bring things to distract you, bring an open mind, because chemo is not necessarily going to be what you think it is. The first couple of sessions, I don't think I had any side effects at all. I was like, “Ooh, this is easy-peasy.” And then the third one I kind of did -- with the first chemo I didn't lose my hair, so that was a good thing, but then later chemos I did. So just bring an open mind. You never know, how you're going to react.
[00:07:22] Dr. Diane: Okay, so let's talk about that, because hair loss is a fear. You have a very famous quote that I think you should share with everyone.
[00:07:29] Stacey: Well, it's that, it's not losing your hair that's so horrible; you could wear a wig, you could wear a hat; it's the fact that cancer walks in the room before you do when you lose your hair. So everybody already knows you have cancer when you walk in. And the word is already demonized, people are afraid to hear people say, “Does she have cancer?” Just say the word, and it's not so bad. You need to face it in order to survive.
[00:07:48] Dr. Diane: It's absolutely right. So Elizabeth, share with our listeners, hair loss, that's clearly, for those reasons, such a striking, powerful shock. Again, it's not just cancer, it's just the obvious external changes. Does that happen right away? And what can we educate our patients on sort of knowing on what to expect on the hair loss side?
[00:08:07] Elizabeth: I mean, as an educator, I feel it's super important to mention if it is going to happen, not all chemo regimens cause hair loss.
[00:08:15] Dr. Diane: I think that's critically important, right?
[00:08:17] Elizabeth: And it's not so important, right. And experience for Stacey is not the same for the next person, and we will make you aware if it's going to happen. And we know from experience that approximately when it would occur and we will make you aware of it. Most of the time it causes hair thinness for most regimens, but there are regimens that will cause complete hair loss, and it is temporary while patients are on chemotherapy regimens and we assure them of that, and then it will grow back once you're off therapy. I know for [indiscernible] [00:08:47] situations, it might be a little bit different, but it is temporary while you're on that specific drug that causes that significant hair loss.
[00:08:57] Stacey: The one where it caused the thinning for me, I waited until I had finished the regimen, the eight sessions, and my hair started to grow back, and that's when I buzzed my head. So it was never completely bald.
[00:09:06] Elizabeth: We never recommend patients to buzz their hair off. It's really very traumatizing sometimes, I mean, I don't know if that experience for you was-
[00:09:13] Stacey: Well, I ended up using it as part of a Halloween costume.
[00:09:15] Dr. Diane: Okay, Stacey, making the lemonade out of the lemons.
[00:09:20] Stacey: It was a really bad taste Halloween costume, but we won the first prize.
[00:09:22] Elizabeth: There we go. [Laughs]
[00:09:25] Dr. Diane: Is worth it. Elizabeth and I cared for a patient and he came in one day and he had a long ponytail. And all the members -- he was a sanitation worker, and all the guys in his office essentially decided they were going to buzz their hair to support him, except he was on a chemotherapy regimen, it didn't cause hair loss. So there it was. He's kept with his ponytail and all nine guys were bald. But I think it does tell truth just culturally, it's a hard thing for people to swallow when you lose your hair. Most times, like you said, it's important to ask the oncologist when it might occur. In our world it's usually sort of right before the second treatment, but that certainly varies. So it's not usually immediate and sometimes like you said it can take that much longer, so it's not a one-size-fits-all.
[0:10:05] Elizabeth: And again, it depends when the second treatment is, I mean, if it's two weeks or three weeks.
[0:10:10] Dr. Diane: What about nutrition E, how can you -- sorry Elizabeth’s nickname is E.
[0:10:12] Elizabeth: We always recommend balanced everything. We do not recommend cut out all sugar, we do not recommend no meat diet. It is as tolerated as best really those couple of days after your chemotherapy session where your nausea and vomiting symptoms or feeling fatigue is the highest. It is okay not to eat a full-blown meal those days. But it is important to hydrate and to eat very small meals and whatever you crave those days. And then once the chemotherapy side effects wear off, you will be able to then increase your food consumption. I know it varies depending on your diagnosis and things like that and what you can and cannot eat, but we don't recommend drastic diet changes.
[0:10:59] Dr. Diane: Is it common to lose weight?
[0:10:59] Elizabeth: It is. You can, but then depending on the regimen, again you regain it back. It really is minimal changes that we do keep track of and if things are changing, then we will bring light to that. And most of the times when that happens is because they've really made drastic changes to their diet, but-
[0:11:15] Dr. Diane: In fact many times they may even gain weight because the steroids that we use, which is a powerful anti-nausea medication.
[0:11:20] Stacey: You can end up eating a lot of crazy food, but hydration is key. And if you can't actually drink the water, you can go for a hydration session.
[0:11:28] Dr. Diane: Right. So if you have a little bit of nausea you can get intravenous hydration, which is a really powerful anti-nausea remedy. Did you feel like you gained weight or lost weight or-
[0:11:35] Stacey: Both. Right now I'm in a period when it's not a balanced diet, because if -- I'm on a no fiber diet, which is counterintuitive to every other diet in the world, so I've actually lost some weight because you can only eat so much processed food. I'm pretty good at it. But you can only eat so many Kansas spaghettios and chocolate chip cookies, but that you know-
[0:11:53] Dr. Diane: After surgeries and chemos, it's hard-
[0:11:55] Stacey: Right. You can find around about that too. I'm literally on a no-fiber diet, so I drink juices to get the nutrition in. So I feel pretty healthy.
[0:12:01] Dr. Diane: And I think that goes back to you. You have to drink-
[0:12:04] Stacey: Drink, drink, drink.
[0:12:05] Dr. Diane: Right, drinking in as many calories as you can get from the drinks if you can't eat regular foods is critical. Talk to us a little bit about how you recommend or advise patients on their own immunity, and do they wear masks after chemo, can they go on public transportation, buses, movie theaters, etcetera.
[0:12:21] Elizabeth: Usually the chemo regimens that we recommend or provide, you do not have to wear masks. Good hand washing is what we recommend. Cover your mouth with your elbow, you know when you cough, you can be closer, your family members, obviously you use common sense. If your children have things that are communicable, then you will kind of stay away from them. But you do not have to isolate yourselves. We want you to be surrounded by your loved ones, because that really helps in order for healing and things, and to improve your health status.
[0:12:56] Stacey: And get you vaccines; you should always be fully vaccinated.
[0:13:00] Dr. Diane: Absolutely.
[0:13:00] Stacey: I do try to avoid -- anybody with a cold I try to avoid, anybody who hasn't been vaccinated and I give the turn my head away hug to most people, because I don't know what my immune system is doing. I don't know what I'm going to contract from anybody.
[0:13:12] Dr. Diane: Yeah, and I think that's critical. So in patients that have blood cancers - leukemias, lymphomas, their immune system is inherently off because of the nature of their cancer. But most patients that have cancers that start in what we call solid tumors, breast cancer, colon cancer, stomach cancers - those patients in general, their immune system is intact. We want them to avoid clearly anyone that's sick, but you don't need to wear a mask. You can go to a movie or go bowling or do the things that are important to you. But certainly if you had a fever, you need to call right away. And that's because there may be your own bacteria within your own mouth and bowel and other places that can go where it shouldn't go when you're on chemo, and that could be potentially serious.
[0:13:53] Elizabeth: And part of my education to patients and families are to call when you have a fever, when you have symptoms that don't resolve within 24 hours, and when you're just not feeling yourself and things are really out of the norm, it never hurts to call and not to wait until your next clinic visit because you're definitely afraid that I'm going to send you to the emergency room.
[0:14:14] Stacey: I used to hesitate about calling, because I didn't want to come in to-to go to the emergency room. But you know, I've got all kinds of stomach issues, and you've always walked me through it, and I've-I've never actually had to come in for any of them.
[0:14:22] Dr. Diane: Yeah. And we think that's so critical to emphasize, patients get afraid, because they don't want us to tell them that they have to go to the emergency room and they're afraid of what we're going to say. But chemo is tough and it is potentially very dangerous if you don't do what you're supposed to do. So I think we've really want to emphasize that point that there is no silly question, you should always err on the side of calling.
[0:14:40] Elizabeth: And there's so many side effects that we can just like Stacey said manage at home, and for you to suffer at home it gives me the heebie-jeebies because I could have helped you, I could have helped anybody that's on the phone.
[0:14:54] Stacey: It's truly as hard to ask them. People say give me a call and you're not going to really give people a call. Your friend should be saying to you, "What can I do to help," but it's more than just the food things too, this exhaustion from chemo, some of them make you -- I don’t mean exhausted like I need to take a nap, I mean exhausted, like I can't lift my arms. So you need to deal with that too.
[0:15:11] Elizabeth: As the nurses and doctors and the health care providers get to know the patients and their family members, I oftentimes I'm telling you as a patient, but then I look towards your loved one to say, you need to make sure we call so that we can prevent any other side effects from going awry.
[0:15:28] Stacey: So somebody is going to change my husband's entire personality and make them more attentive, right.
[0:15:32] Elizabeth: I promise you that.
[0:15:33] Dr. Diane: Let's talk about being attentive. Anything else that you tell your patients as it relates to the chemotherapy side effects?
[0:15:40] Elizabeth: Anything like I said that lasts for over 24 hours, you have to call the office. I encourage exercise as tolerated those days that you're not super fatigued. I encourage patients that you can drive and you can work depending on your side effects, and you can be sexually active. We don't want any babies while you're on chemotherapy to be conceived, no making babies, because that's a very important aspect of humans. And many times just like you said, people don't want to call to ask for help. Many people don't even want to bring up that subject. So, I tell-
[0:16:13] Stacey: If I wanted to bring it up beforehand. [Laughter]
[0:16:16] Dr. Diane: Now we can give you an excuse if you didn't want to, but-
[0:16:18] Stacey: My husband is going to kill me.
[0:16:19] Dr. Diane: In fact I think that's critical, because your quality of life is so important and the connections with your loved ones need to be as-
[0:16:26] Stacey: Your life is not over because you have chemo, your life is changing. It's a moveable feast, you do a lot of things differently, but you don't have to stop anything really; nothing that I could think of.
[0:16:35] Dr. Diane: Yeah, there's just bumps in the road that you need to figure out how to jump over, right?
[0:16:39] Stacey: That's right. And you know, initially for the first I don’t know, five years or so, I did think of it although it wasn't five straight years of chemo, I did think of it as poison. What am I doing, I'm putting this poison into my body, but then we've talked about it since now that it's maintenance chemo and we're working on trying to find a cure for me. I see it as life saving. It's no longer poison. I see it as a necessary evil. It's going to get me to when you find a cure.
[0:17:04] Elizabeth: And we acknowledge that. I mean, we acknowledge that we are the poison pushers like Dr. Reidy would say. But we also like you said, nothing is so black and white, we have modified the ranges of time that you get chemotherapy so that you can fit in that trip, and that you can go to that important event so that we can make sure that we listen to what is so valuable to you and help you live life.
[0:17:30] Stacey: About the same time I was originally diagnosed, a friend of mine who has unfortunately since passed, we had a discussion about whether or not I should get a port. That's the Mediport that's put into your-
[0:17:39] Dr. Diane: So that's a big IV that goes underneath your skin in the chest-
[0:17:42] Stacey: Right, and the catheter goes right up into a vein into your neck. And he didn't do it and he regretted it. Because getting chemo in your veins on your arm is much harder than getting into the Mediport.
[0:17:53] Dr. Diane: Yeah, you can take blood from there, it becomes your best friend. I agree, patients don't love another procedure.
[0:17:57] Stacey: It becomes a badge of honor when other people see it, you know, like on the beach, somebody else once saw it and we were like we saluted each other.
[0:18:02] Dr. Diane: In the club; they necessarily want to be part of.
[0:18:05] Stacey: Club cancer, club med.
[0:18:05] Dr. Diane: Have you ever had chemo fog?
[0:18:08] Stacey: Oh, chemo fog, we're either blaming my age or the chemo these days. It's not contagious. No matter what anybody in my family says, chemo fog is a real thing. It's a little scary. It's not like you forgot somebody's name. Sometimes you just-just stand there like I did it earlier today, I just said I couldn't remember the question. It's not just because I'm speaking a lot, I'll just be in the middle of something, and then if you don't let me finish what I was saying, I'm not going to remember what I was saying. And it's a real thing.
[0:18:33] Dr. Diane: And I think there absolutely are studies to prove that so-called chemo brain, and hopefully ways to adjust when that happens. But it's just the ability to respond as quickly as you used to is probably a little bit off with chemo.
[0:18:45] Stacey: And you got to let people know, you know, your friends and family know, you just -- when you can't remember something and you're confused and they look at you like you've completely lost it, you just say chemo fog.
[0:18:54] Dr. Diane: So I thought we'd do a quick couple of myth-busters because there are certain things that patients would have -- I want to use these for Elizabeth. Just a quick True and False on this one. There's only one type of chemotherapy and it kills both bad and good cells.
[0:19:05] Elizabeth: False false.
[0:19:07] Dr. Diane: Chemo will always cause hair loss. True or false?
[0:19:09] Elizabeth: False.
[0:19:12] Dr. Diane: Chemo will not enable you to have a child after chemo.
[0:19:14] Elizabeth: False.
[0:19:16] Dr. Diane: Absolutely false, right. So we've had many patients that have gone on after chemotherapy to start families. And so we've even rarely treated women when they're pregnant in their third trimester-
[0:19:24] Stacey: That must be tough.
[0:19:16] Dr. Diane: And patients are -- yeah, that's been tough, but successfully went on to have children. So again, it doesn't kill all the bad cells and the good cells, and you absolutely can go on and have a life thereafter when you're done with treatments which is really important. So Stacey, I'd like to end on how do you live with this on and off chemotherapy treatments for so long, because we recognize this is not an easy one to endure, and yet you do it. You're our inspiration, that's why we invited you to be here today.
[0:19:55] Stacey: Thank you. I don't see a choice. I've told this story many times when my father died when he was eight days shy of 52, had he lived two more years, he probably would have lived 10 more years. Because there were so many new drugs coming out right then in 1985. I see chemo the same way, I see all the advancements in cancer research. So I don't see where I have a choice. I'm not ready to go, my family needs me, my dogs need me.
[0:20:19] Dr. Diane: Tell us about the safe.
[0:20:19] Stacey: My husband doesn't know how to open the safe. I'm not even sure he knows where I put the combination. And I mean, I could put it on the safe, he's still not going to be able to open it because I haven't shown him how. And he doesn't know the passwords to all our accounts, and he thinks that's what's keeping me alive is that he can't get into anything so I have to stay alive. So that's it, it's the safe, he would have to get dynamite to open it. His passport is in there, but other than that there's nothing in there that he really needs. But that's -- I'm not ready to go. I want to fight and I've always been a fighter and it's not a matter of quitting. It's not a matter that it's not tough; chemo is really tough. I'm not ready to die. I haven't read everything yet, and I want to read more.
[0:20:57] Dr. Diane: Yeah, you’re a big reader. And I do want to highlight you were on a clinical trial with immunotherapy treatment, could you tell us a little bit about that?
[0:21:03] Stacey: Great. I mean originally the days were very long, the first few days were 13 hour days, I watched the entire Game of Thrones in like three or four sessions, I caught up very quickly.
[0:21:15] Dr. Diane: That's one way.
[0:21:15] Stacey: And it was great except I scared the nurses when every time I screamed, that Red winning really scared everybody. Side effects are much less with immunotherapy than they are with chemo. And they're exactly what they tell you that they're going to be. It is literally black and white. And it worked for over a year. And it would be lovely to get into another immunotherapy trial, but I think it's kind of difficult once you've been in one. So compared to chemo, it's much easier and there's only so many trials out there.
[0:21:40] Dr. Diane: Yeah, well we're going to find one for you if we need it.
[0:21:43] Stacey: Please. If you're going to make me a guinea pig make me a guinea pig like I said.
[0:21:45] Dr. Diane: There you go. It is extremely brave thing, and thank heavens like you said it helps for over a year but-
[0:21:49] Stacey: There is side effects with that too.
[0:21:45] Dr. Diane: There are always side effects and there are risks of the unknown.
[0:21:54] Stacey: Because the side effects with all the different chemos like there is the hypersensitivity to cold that I have now, there was -- with the oral chemo with your hands hurt -- your hands and your feet hurt. But you learn to live with each one and you know, makes you stronger; Nietzsche - what's not killing me is making me stronger.
[0:22:08] Dr. Diane: E, any other closing comments you have?
[0:22:11] Elizabeth: I always recommend: ask questions, write down your questions and bring them over. It is very overwhelming when you meet the doctor for the first time, and then I go in afterwards and bombard you with so much information, right. So my role is to assess whether you're ready to learn, how much should I give you, and work with you. You know, it's not a one-way street; it's a two-way street. And that's how it would make it a lot more successful. So write down your questions. Do bring somebody with you, you have that extra pair of ears, and somebody that you trust and that you feel comfortable with. And again, just ask questions and go back to your sources like your doctor and your nurses for information. Don't try to limit the doctor Google, you know, and things -- sources that are not as reliable because then that just overwhelms you even more.
[0:23:00] Dr. Diane: That’s absolutely right.
[0:23:00] Stacey: And the people you bring with you, the people that it's more than you're comfortable with, you have to be able to sit with them for five hours if it's going to take that long. You have to be comfortable with them seeing you at your worst, and be comfortable with maybe not talking for five hours, you're just going to sit there. There are some of the drugs that they give you to counteract the side effects that you literally can't speak, so you're just sitting there.
[0:23:21] Dr. Diane: That's great. Some people say you want the people that can make energy, not take energy.
[0:23:25] Stacey: Exactly.
[0:23:25] Dr. Diane: You really want to surround yourself by people like you said, that just can live with you in that moment and-
[0:23:29] Stacey: Positive energy.
[0:23:29] Dr. Diane: Yeah, right. Thank you both so much for coming to be part of the show today. Elizabeth Cruz - my dear nurse, and Stacey Peltz for sharing your incredible brave story with us. Thank you for listening to Cancer Straight Talk from Memorial Sloan Kettering Cancer Center. For more information or to send us any questions you may have, please visit mskcc.org/podcast. Help other people find this helpful resource by rating and reviewing this podcast at Apple podcasts or wherever you listen to your podcasts. These episodes are for you, but are not intended to be a medical substitute. Please remember to consult your doctor with any questions you have regarding medical conditions. I'm Dr. Diane Reidy Lagunes onward and upward.
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