The Rise of Lung Cancer in Women and Never-Smokers

[00:00:00]When I was told that I have lung cancer, I was in shock. Lung cancer is killing more young, healthy women than breast and ovarian [music] and colon cancer combined. This is a women's cancer. This is a women's health crisis. [music] If this is killing all these people, why aren't we doing something? This lung scan [music] is so easy. It's so easy.

[00:00:20]It is a very curable [music] disease when we find it early. You know, my sister is not here and she is. [music] I think my be all end all goal with everything is to make cancer a chronic illness. We die [music] with not from.

[00:00:35]There is this opportunity to drive awareness and I think drive change.

[00:00:39][music] This show is sponsored by United Health Group. We know women live longer than men, but did you know they spend 25% more of their lives in poor health? How can that be? Well, it's that women's care is often treated as isolated moments instead of a lifelong experience. That's why United Health Group is working to reshape women's health with a more connected approach to care, supporting women through every stage of life from adolescence to menopause and every moment in between.

[00:01:12]This year, United Health Group was the first to expand coverage for doula care nationwide, helping more women access personalized support before, during, and after birth. And through community partnerships and inhome care, United Health Group is helping women with the greatest needs detect and prevent diseases like cancer and heart disease earlier. Because women's health is more than any single diagnosis or moment in time. It's about care that follows women [music] throughout their lives.

[00:01:41][music] I learned something really interesting lately that surprised me. The most common cause of cancer death among women in the United States is lung cancer.

[00:01:53]Yes, that's right, lung cancer. In fact, lung cancer causes more deaths each year than breast cancer, pancreatic cancer, and ovarian cancer. I know it's hard to believe, right? And part of the reason is that once someone experiences symptoms, it is often too late. And many of those who are ultimately diagnosed aren't even eligible for screening under current guidelines. So the people here with me want to change all of that, improving access to screenings and to help create new ways to detect lung cancer, including a bloodbased test. So Ann Wiski is the co-founder and CEO of the personal genetics company 23 and Me.

[00:02:36]Her sister Susan, the former CEO of YouTube, died two years ago at age 56 years old from lung cancer. Shar Bowler, has never smoked, just like Susan never smoked. And she's a mother of four and was diagnosed with stage one lung cancer at age 43. Right. We also have Dr. Kim Sandler here, a globally recognized radiologist who has made it her mission to expand access to screening, especially for women and non-smokers.

[00:03:06]I'm so glad all of you are here and thank you Shira for your book which Ann wrote the introduction to because it's been a wakeup call for me as well and I know you want it to be a wakeup call for all Americans and especially women. Um sure how did we get here? You know when I was told that I have lung cancer I was in shock because I'd never smoked a cigarette. My dad being a lung doctor taught us, don't smoke, your lungs will be fine. And that just isn't the case.

[00:03:37]And I had to teach him that. And it was something that came as a shock to me. I know it came as a shock to Ann when she went through it with Susan. And when I had to call Ann and say, "Uhoh, it's my turn." We both realized that something had to change. And I think that we don't know why. We don't know why lung cancer is killing more young healthy women than breast and ovarian and colon cancer combined. The doctors don't know yet.

[00:04:02]But what we can do is we can screen people just like a mammogram or a colonoscopy or a skin check. And if we can catch it in stage one, like I was lucky enough, I have a 90% chance of survival. And the problem is we don't feel our lungs until it's too late, until the cancer spread to our bones, to our brain, and then it is the number one cancer killer.

[00:04:23]>> You know, and um I've known you and your sister for a long time. interviewed your sister who was the CEO of uh YouTube. Um Google was graded in her garage.

[00:04:33]>> Yeah, it was >> mother of five.

[00:04:36]>> Um >> couple years before she passed, she came to my house >> in Washington. We went for a walk >> um together and she was the picture of health.

[00:04:45]>> Mhm.

[00:04:46]>> What have you done now since Susan's passing? And what's your mission?

[00:04:49]>> When Susan was diagnosed, it was a total surprise. So, similar to Shar, like Susan was focused on her health. She was wildly compliant with every recommendation that was out there. She was always doing, you know, her mammograms on time, colonoscopies.

[00:05:04]And I remember she had this, she just kept saying like lung cancer like lung like like no one ever told me like lung cancer is like even on the radar. Like how like how is that possible? Like I would have done something if I had known. And she was so shocked by the statistic that lung cancer kills more people than colon, prostate, and breast combined. And she kept saying like, "How is this po like if this is killing all these people, why aren't we doing something, right?"

[00:05:34]>> And so Susan Susan's one for action like we joked like Susan um you know, Susan was the CEO of YouTube, but then she became the CEO for cancer and she had her deputies. Like we we joke like Susan was a CEO, my sister was the chief medical and I was the intern cuz like once you're the little sister, you're always the little sister.

[00:05:52]>> And your your other sister is a doctor.

[00:05:54]>> My other sister is she's an epidemiologist, but she's at UCSF. She's very competent with all of this. So, um we kicked into action and I that first weekend like we called 65 people, >> 65 people that I knew from my investing days and we were like, we're going to figure this out. Like who are the right people who are making a difference on detection? like first off why did she get lung cancer? She wanted to know. So like who's doing that research on the why? Um how do we better detect this?

[00:06:21]Because now she is worried about her kids. She's worried about her sisters like everyone. And then the treatments like what are the treatments that have this? So since Susan's passing we have launched the Susan Wiski Foundation and the Susan Wujiski Foundation is really now focused on the why. like why are people like what's the environmental what are the causes that are driving this increase in lung cancer particularly in women how can we detect it and so what is it we can do like how is it Shar's case was extraordinary that she found it early but how is it that all of us can detect lung cancer and how can we create a regular screening program and then we want to drive awareness like everyone needs to know and that they have this opportunity to go and get screened >> everyone does want to know that I mean everyone wants wants to know that I want to bring in Dr. Kim Sandler. And your your connection to the story is incredible because it just happens that you and Shar first are friends who enjoy sushi together [laughter] in Nashville, but then you also happen to be an expert in this.

[00:07:22]>> Yeah. So, Shar and I became friends, I think almost five or six years ago now, and we met and you know, you meet someone and you're like, "Oh, no. This is this is my people." Like, we we just liked each other immediately. And we would go to lunch and I would talk about the lectures I were giving, the talks I was giving, the research I was giving, and it's all in lung cancer and women.

[00:07:38]that has been my focus for now over 10 years. And when Shur was diagnosed, she said to me, I always thought I would get a women's cancer. And I said, this is a women's cancer. This is a women's health crisis, but we don't talk about it. And women are so good at being our own advocates. And I think breast health has been such a great example of that. We have taken this on ourselves to be like, we are going to advocate for ourselves.

[00:08:00]We want to have this test. We talk to our friends. We talk to our family members. You have to do this. And we have to do the same with lung screening.

[00:08:07]And as you were alluding to the eligibility criteria right now, it's only in people who have smoked. And we need to really start to raise awareness around the fact that yes, we need to screen people who have a significant tobacco exposure. But if you look at women worldwide, over 50% of lung cancer in women worldwide are in those who have never smoked. And we have a test with low doct that can find lung cancer early when it is most treatable, most curable.

[00:08:33]And so we really need to better understand the risks and benefits of the screening tests when it is most appropriate. But we have an opportunity to start saving lives right now if we can find this disease early. And so we need to continue to do that.

[00:08:46]>> I think people will hear that what lung cancer is a women's health crisis.

[00:08:50]>> What do you think?

[00:08:50]>> Absolutely. So as we've been saying it kills more young healthy women than breast and ovarian cancers combined. And those are the diseases that we are always concerned about. And just because we're advocating to screen for lung cancer doesn't mean we should stop screening for breast cancer or stop having skin checks or start stop doing all of the other things that are so important. But we have to understand that as we've started to see the smoking rates come down, the lung cancer rates are not coming down in women the way that they should because there are more and more cancers that are not related to tobacco exposures. There are environmental exposures. There are genetic predispositions. are these things that we are starting to understand but we need to do more work and blood tests are going to be an enormous part of this but the more cancers we diagnose the more lives that we save we also are going to give ourselves the opportunity to better understand this disease and why it's occurring and when we can find it early and when we can treat and cure people there's two pieces of research that um I want to mention one Kim did and it was that breast cancer survivors and we all have so many friends that are breast cancer survivors today luckily actually have a two-fold increase of getting lung cancer as a primary cancer, not a metastasis, not due to the radiation treatment, just as a primary cancer. And I think we should be telling women that there are so many of our peers that are breast cancer survivors and if they get a lowd do CT when they go in for those mammogram checkups, they could catch it earlier. And I think that's important.

[00:10:18]It's part of the women's disease. I think also they found in Asia that women that had never smoked a cigarette in Asia were getting lung cancer at a faster rate than the men who did smoke.

[00:10:29]And both of these point to the fact that it is a female health crisis. What do we know then epidemiologically about why this is happening to women?

[00:10:37]>> Yeah, I think and I think that Ann and her team are doing some really great research looking at things like germline mutations and better understanding why these cancers are manifesting. What we saw in the women who are having lung cancer after breast cancer is it's often women with hormone negative disease.

[00:10:51]These younger women with more aggressive tumors and we looked at the lung cancer incidents within 5 years of their breast cancer. So really if we think about radiation induced malignancies, it takes much longer. So these are genetic predispositions to developing cancer.

[00:11:04]And Shira told me recently that she hates it when I say this. So I'm sorry I'm going to say it again, but I think we think about cancer as lightning striking. I've had this disease. I should never have to deal with this again. I'm so fortunate that I've come out on the other side. And the truth is that once we have cancer once, we're actually at an increased risk of developing cancer again. And lung cancer is the most common cancer to develop after breast cancer. And we don't talk about it and we don't talk to women about their risk. And again, we are such fabulous advocates for our health, but this is part of our health journey, too.

[00:11:35]And we really need to shine more light on it. I'm so glad you said that because I don't think that I have ever heard and as you pointed out Shira, many friends have had breast cancer, luckily getting catching them much earlier because of the screening, but then they're going and getting their low CT lung scans.

[00:11:53]That's just not even on their radar. I think that's part of the guidelines. I think that right now you have to be over 50 and smoke a pack a day for 20 years.

[00:12:01]That's just not what we should be doing.

[00:12:02]That's antiquated. I think that it would be beautiful in a society where we did it similar to a mammogram at the age of 40. But at the very least, the lowhanging fruit with breast cancer survivors or occupational hazards or burn pits for veterans, we should be able to give them an opportunity, those type of patients to get it. You know, for me, I don't hit any of those. I didn't have radon issues in my house, which is the number two reason behind smoking that they believe right now. I don't have an occupational hazard. I was not a burn pit veteran. Um I'm not a breast cancer survivor. So none of those hit mine. But I was lucky enough to catch it early because I advocated for myself because I went and I got the scan on my own. I paid out of pocket and I and I pushed forward. Radon. Let's just stay on that while we're there because you did talk about where you grew up in California though might have been an area where there was larger radon exposure. My sister is a surgeon. I was talking to her before this and she said, "Oh yeah, I remember the house that we just bought actually had increased radon and I made sure we took care of that and da da da da da." So again, people are like, "Rayon? I I do I I need a radon detector." What would you recommend in terms of that?

[00:13:13]>> I would recommend a radon detector.

[00:13:15]>> A [laughter] radon detector. Like I actually have one now in my kitchen and it's because we're doing we we we renovated our pool and so it was like actually interesting to see how much it also fluctuates. So you can get, you know, radon comes from the ground and so basement it's helpful to get professionally tested or you can buy some of these monitors online, but getting your basement tested because you just don't know. It's not something you can smell. It's not something you can see. You need a detector. And so right after Susan was diagnosed, we actually professionally got someone who went into my mom's house, Susan's house, my house to understand, and we did not have that.

[00:13:48]But it is absolutely something that it's relatively low cost. People can go and get detected. I'm I'm curious an given that you are founder of a company you called everyone you and your sister you know every health expert um that you know what did you what was kind of mind-blowing to you and all those conversations that you had I mean what was mindblowing was that you know my sister and I wrote um a piece called you know where's the pink ribbon for lung cancer and what was mindblowing for me in those conversations was a bit of the acceptance that oh lung cancer you just find it laid and it's really tough and um you know for me the fact that there was not there hasn't been enough advocacy and there's a couple groups that are out there there's some people that we met on Facebook and or yeah Facebook now um that and Reddit and other groups like that were just extraordinary with their knowledge and that were advocating and helping people but I I think there's been sort of a complacency that lung cancer is just killing a lot of people and smokers and it's a smoker's disease and that it's late stage which is not and I think that's what's been amazing about all of us teaming up is that there is this opportunity to drive awareness and I think drive change and I think I go and I get my lowd dose chess CTS um we've had other people do it there's actually countries that are actually instant you can talk more about those but there's countries that have actually implemented like whole nationwide testing programs and finding I can't remember it was like 3 to 5% of people were actually finding that they had an early malignancy. So there's reasons to do this but I think we as a country are not strong on funding prevention and funding early screening. We're strong on treatments and so that's specifically what we are eager to change. So the Susan Wujiski Foundation has been raising money specifically to help advance the knowledge around what you know what can people do um advocating for screens, advocating for blood cancer or the blood um screening tests um and doing research on really trying to understand what is the right type of screening guidelines and also why are people getting this because there is an increase and we're eager to see like what is it in the environment? What is it about where you're living? What is it in terms of how what are you exposing yourself to? Is there something that's there that we can also detect around the why?

[00:16:20]>> Well, thanks to all of you, I did have a lowd do CT scan today. Super easy.

[00:16:27]>> I mean, super quick. It's incredible.

[00:16:29]>> I know. I was surprised too when I first did mine, >> you know. I mean, I, you know, we think about a colonoscopy. Also, not horrible, you know, but not great, you know, but it's fine. You know, you get it over with. You know, a mammogram can be uncomfortable.

[00:16:42]>> Yeah. Um, as my good friend Gail King always says, you know, if a guy had to do that with his, you know what, [laughter] and get it smooshed, they would change how to do a mammogram. But that's okay. It's a good It's a good screening test. It's [laughter] a good screening test.

[00:16:53]>> Got to love Gail King.

[00:16:55]>> Totally.

[00:16:55]>> Yeah. But I mean, this lung scan is so easy. It's so easy. And yet, Dr. Pow at New York Presbyterian told me today that even those that are eligible, which which by the way is pretty strict. you have to smoke a lot of packs of cigarettes and be over 50 years old, right, that only 20% get screened. So, we're we're so far away >> from the type of screening that needs to be done, right?

[00:17:19]>> Yeah. And so, lung screening has been covered by insurance companies now for a little over 10 years. So, it's still a relatively new test compared to some of the other screening tests that we have done. Personally, I feel that the stigma around smoking and we talk about all of the amazing work that was done for smoking sessation. The stigma is so strong that to expect someone to come into their doctor's office, talk very openly about their smoking history, particularly if they're continuing to smoke, and to advocate for themselves to say, "I want to have this test." If their doctor hasn't said, "Hey, I think this is maybe something you should do."

[00:17:49]That is a lot to ask of someone. I actually think that if we expand the guidelines beyond smoking, which we absolutely should do because we are seeing cancers as a result of so many other types of exposures and predispositions, if we made it more widely available, I actually think we would have much more uptake in the smoking population because it's less about blame and and we really try to stay away from stigmatizing language and we really try to be really encouraging.

[00:18:15]There's a lot of nihilism around lung cancer because we often do find it so late. But the more that we can raise awareness on what early detection means and the more that we can encourage everyone and really start to expand the guidelines, I actually think we're going to see a much better uptake in people that are at higher risk because of tobacco exposure.

[00:18:32]>> So what is the goal in terms of expanding screenings?

[00:18:37]>> What do you want it to be?

[00:18:39]>> I mean I would love it to be 40 and older just like a mammogram. I think it would be a really easy thing for a woman to say, I'm going in to get my mammogram and I'm going to get my lowd do CT, you know, get all the screening in one. Get your skin checked as well. I just think that's an easy entry point. There's not that much testing around it yet. So, it's going to be harder, I think, for the United States Preventive Services Task Force to maybe wrap their head. And that's why I talk about the lowhanging fruit, the breast cancer survivors, um the people with the occupational hazards. But I think as Kim said with the stigma, it's true. I would tell you that being a lung cancer survivor is a lonely place because there aren't many of me. And when I do find them, oftentimes they don't want to talk about it. They don't tell their family and friends because of the stigma, even if they weren't big tobacco users. There's a stigma around it that >> makes people a little bit embarrassed. I think also if you look online it's scary because the stats are so bad. But I think what people should embrace and recognize is if you find it early it's curable >> and so you should embrace finding it early because you can absolutely then go and manage it. I think also just want to tap into the AI world here. It's extraordinary what's going to happen with you got you got your CT now, but that's going to be like your baseline, right? And there's all kinds of extraordinary research happening about using that using AI to then give you a 5-year likelihood of developing lung cancer. And so you can imagine a world where your CT is actually not annual, but you go and you get your baseline and then they say, "Okay, you Nora, you need to come in every 3 years and you should come in every five. Sher, you're going to come in every 10." So you can imagine a world where you'll have like true personalized information and that might be a combination of a scan, your genetics and AI all looking at your lifestyle, how you've lived and then giving you a prediction about how often you want to come.

[00:20:34]>> And in fact and do you believe too that that [clears throat] is the future of medicine because of AI that we're going to have a number of baseline tests not just even on the lung? Yes. And and this is soon. I mean this technology is available and the risk prediction models in terms of your clinical risks are available where we can say in the next 5 to 6 years this is your likelihood of developing lung cancer based on your CT and the AI algorithm based on whether or not you've had a family history of lung cancer or a personal history of other cancers. And ideally the next step is the bloodbased biioarker. So how do we then combine all of that? And we are very open to personalized screening recommendations. We talk about colonoscopy. If you have a polip, you come back sooner than someone who doesn't have a polip. If you have a family history of breast cancer, particularly in a woman who's younger, your screening recommendations are different to someone who does not have that history. We are already embracing this in all of these other cancer types.

[00:21:24]It's time to move towards personalized screening for lung as well.

[00:21:27]>> So this is a good time to ask that question. So what is a biioarker?

[00:21:31]>> So when we talk about biomarkers or bio repositories, they can be blood tests.

[00:21:34]There there are imaging biomarkers. So Ann talked about the AI algorithms that we use that is a biioarker where we can look at your scan and ideally we don't just look at one finding. We look at the entire scan almost as an overall health assessment about what your risk is. And then with blood-based biomarkers there are a number of different ones that we can look at. They're circulating tumor DNA. There are different protein panels.

[00:21:55]They're growing and evolving at such a rapid rate. And there are things that we're looking at now that we never even thought about 10 years ago. And it's really advanced in the surveillance space. And Shira can talk about this from her own experience in terms of once we have a tumor, the likelihood of then finding those tumor cells circulating before we might see them on an imaging study and that's come an enormous way.

[00:22:16]The piece that we're missing and I think Ann can speak to this more is the early detection piece specifically in lung.

[00:22:22]>> Yeah. So is there a bloodbased test?

[00:22:24]Well, this is what's coming and this is what I think is so [clears throat] exciting and this is I'd say one of the anchor projects of the Susan Wajiski Foundation is actually creating this bio repository of individuals who've had stage one cancer so that we can go and help help all the different companies developing these tests to determine what are the proteins that you want to be measuring. How accurate can you actually measure lung cancer in a stage one where it's like again it's really early but it's then really treatable and you've seen some amazing results from like there's again front page of the newspapers lately about these 14 protein tests that were coming out and able to predict lung cancer. So we're specifically focusing on making sure that we're detecting it accurately in a non-smoking population as well as a smoking population. So, we're funding those studies now, we're helping to make sure that we have all those resources for all the companies that are doing the work.

[00:23:18]>> So, what would that look like?

[00:23:19]>> That would look like an annual blood test that you go and same way you get a cholesterol test, >> you would just go and you would get a test and you're looking at 14 proteins and you're saying like, "Okay, here's whether or not they they see changes that look like you're you have early lung cancer."

[00:23:33]>> Wow.

[00:23:34]>> That's what it's like. The the bloodbased test, it's going to be and there's it's happening all over in breast and other areas. So m now what we're focused on is like making sure that it's really specific for lung that it's going to be accurate that it's going to be sensitive that meaning that you can actually detect it in a you know 95 like a large percentage of the of the people who actually have lung cancer.

[00:23:57]That's the main thing is you want to make sure that it is sensitive enough that it's truly an effective screen.

[00:24:03]>> And are there genetic >> biomarkers for lung cancer and do we know what they are?

[00:24:09]There's not. So there's there's one that we actually have been working on um that again 23me has been working with a number of academics on and it's a variant in a gene called eGFR. And so this is one where um we are working on this. We've been doing research and we are looking to put out a report specifically to individuals who have this variant in EGFR and are much higher risk for lung cancer. So we're also looking to do can we create a what's known as a polygenic risk score meaning look at hundreds of different um you know genetic variants and add that up into a score. So we are absolutely focused on getting a test out there to individuals and the reason why it's so important is because you can do a screen.

[00:24:52]>> Yeah.

[00:24:52]>> Because you can do something about it.

[00:24:54]You find out you have a risk factor now you can go and do something.

[00:24:58]>> Yeah. [clears throat] And I think unfortunately lung is quite far behind a lot of other types of cancers because for so long we just attributed it to smoking. And yes, smoking drives lung cancers, but there are other things that drive lung cancer as well. So we're having to catch up to a lot of the other diseases. And it doesn't mean that we shouldn't better understand the development of lung cancer in people who smoke. It's still really important that we continue to investigate that as well because not everyone who smokes gets lung cancer. So are there opportunities to actually better understand something that might be preventative in people that have these exposures that are not developing lung cancer? So all of this data needs to come together and and to work together. But I think for so long we felt like well if we are able to bring smoking rates down then the lung cancer rates will fall as well.

[00:25:38]>> And they haven't in a way that we would have anticipated that that they should.

[00:25:41]And so that's why all of this work is so unbelievably important. And like Ann said, you know, the CT scan is there and I think we believe everyone should have an opportunity to have one. We don't necessarily know how often someone should have one. We're still trying to figure that out. But if you had a blood test that said, "No, this is now the time for you to get the imaging," then how much could you decrease the false positive rates on CT imaging? If you use the blood test to inform one, whether or not you get scanned, and two, if you find something, what is the likelihood that that is cancer versus benign disease?

[00:26:12]>> One thing I want to add is 23me did launch the lung cancer genetics community after when Susan was diagnosed. And this was really important to Susan because she recognized we don't know a lot about genetics and lung cancer. And so anybody who has lung cancer today or who has had lung cancer can join the lung cancer community for free, get a genetic test and then participate in research, you know, answering survey questions about their environment, about their treatments, and 23me is specifically using all of that to try and create a test to help people better understand their risk.

[00:26:46]>> Yeah. I mean, I would say >> I was diagnosed in October, so eight months ago.

[00:26:50]>> We should tell that story because we haven't yet. Your name of your book is One Scan Saved My Life.

[00:26:56]>> How you found out that you had lung cancer?

[00:27:00]>> Well, I was going to say that I actually did the blood test that we have today.

[00:27:04]So, there's really only one or two. Um, and it came back negative. So, I did it in September. It said I was fine.

[00:27:09]>> This is for the all cancers.

[00:27:11]>> Yeah, the all cancer test. Um, and so I would love a blood test that works. I've been doing that blood test for years.

[00:27:17]I've been part of 23 and me for >> from the beginning. Um, but I think for me what happened is my husband and I are in healthcare and so we do all the tests. We do the 23me. I've had my full genome sequenced. I don't have any of those markers. Um, I paid extra for the cancer panel. My mom's a breast cancer survivor. She does not have brocha. I do not have broa. So, you can get cancer without these markers we know of.

[00:27:40]There's probably markers we don't know yet. Um, but we, my husband and I had gone and done a full body MRI last time we were in New York, uh, nearly a year ago because it was a new opportunity.

[00:27:52]We're in healthcare. We do all the research and all the things. And it was interesting. It it brought forward a 3.8 cm mass in my lung, but it stated to correlate with symptoms and smoking history. I had no symptoms. I ran six miles that day. I continued to run six miles a week. And I had never puffed a cigarette cuz my dad was a lung doctor and scared us. And it wasn't until Kim took a look at it and my dad and they said, "Lungs are looked at in a lowd do CT, not an MRI machine." That I ultimately had to advocate for myself and follow up. And Kim ultimately was like, I think you have lung cancer, which was unbelievable, just like Susan went through because I didn't realize until that moment, and I remind people often, if you have lungs, you can get lung cancer. And that's the reality. And our lungs don't have nerves. So we don't feel it until it's spread and Susan's hip hurts or things like that or it's in our brain. And so I wrote my book once again saved my life. And Ann and her sister Janet wrote the forward to, you know, bring Susan's life to light too.

[00:28:54]>> And I wrote it because I thought this is crazy. I need to find, you know, more lung cancer survivors. We need to be screening people. All we have today is the lowd do CT. I'm looking forward to the blood blood tests and things like that. But I think what the technology and I I talk about it in the book is going to help us is oftentimes in a lowd do CT or people's family history or their smoking history, you can understand this person is high risk or not or this person has cancer or this person doesn't. But that middle indeterminate group is where the AI and the blood test and the cheek swabs and a lot of this new research that Susan Wajiski Foundation is focused on will help us because doing a biopsy of your lungs is a big undertaking. It is not the biopsy of a breast that we do outpatient for 10 minutes and the radiologist comes in and does it. This is a much bigger invasive procedure that I went through. You're under general anesthesia. you have to be on a ventilator for them to take a piece of your lung because your lung can't be moving to take a piece.

[00:29:55]>> Those are very important procedures if you have lung cancer or or a lung disease that needs to see that. But we don't want to do that if it's not necessary. And I think that's a lot of what this AI and the blood work and stuff like that will help us reduce the band of those indeterminate patients, >> not [clears throat] the ones who have cancer are going to have to go through it versus not. And you have used the the Yiddish word basher to describe that here your new friend that became your really good friend in Nashville was able to look at your full body MRI and when you saw it you said >> yeah we we talk a lot about heart disease and heart attacks and in men and women and how we talk about the elephant on the chest and the pain down the arm and those are the symptoms that men often experience and then when I was in medical school and they would say well who's the person in the waiting room who's having the active heart attack and it's the woman sitting there who just doesn't feel right, something is off, they don't come in with the same types of complaints. And so they taught us to recognize symptoms that they called atypical that are now so universally recognized as a heart attack in women that for us those are typical heart attack symptoms in women. I think with Shira's tumor, you know, we often thought about these solid masses, speculated nodules is what we talk about in the upper lobes. That's what a lung cancer looks like. And in smoking related lung cancer, that often is what it looks like. In young women who more often have adnocarcinoma that's now become the most common tumor type that we see in the lung. They're often part solid nodules. They don't look like a solid mass. They can be very easily mistaken for a pneumonia or another type of infection. And I think when they told Shira correlate with symptoms, the idea was well this very easily could be infectious or inflammatory. It's very unlikely that we would see lung cancer in someone with your demographics. You know, we think we hear hooves, we think about horses, not zebras is sort of what they say in medical school, but this is this is the horse now. These part solid nodules in young women who do not have smoking histories. And we as a medical community actually need to do a better job of saying we don't understand all of the risk profiles, but we need to be better at saying we need to follow this because what I told Shira is it's not necessarily that this tumor is going to grow, but if it's infectious, if it's inflammatory, it needs to go away.

[00:32:08]>> So when I saw the CT scan that came a few months after her MRI, knowing that it had been there in July and that it was still there in September, that was a red flag. No, no, >> that's not an infection.

[00:32:19]>> This is not an infection. This is this is now something that warranted a biopsy. And that's a big decision.

[00:32:28][music] >> This show is sponsored by United Health Group. We know women live longer than men, but did you know they spend 25% more of their lives in poor health? How can that be? Well, it's that women's care is often treated as isolated moments instead of a lifelong experience. That's why United Health Group is working to reshape women's health with a more connected approach to care. Supporting women through every stage of life from adolescence to menopause and every moment in between.

[00:32:57]This year, United Health Group was the first to expand coverage for doula care nationwide, helping more women access personalized support before, during, and after birth. And through community partnerships and inhome care, United Health Group is helping women with the greatest needs detect and prevent diseases like cancer and heart disease earlier. Because women's health is more than any single diagnosis or moment in time. It's about care that follows women throughout their lives.

[00:33:25][music] We are now at the part of this podcast that we call group chat.

[00:33:35]>> [music] >> We're soliciting questions from um our audience and that's part of what this podcast is all about in terms of bringing the world's experts on health, medicine, science, fitness, and allowing people access to them to answer the questions that so many people have about this. So, uh, Pamela from Phoenix, Arizona asks, "Has an increase in vaping or the increased use of marijuana led to the increasing lung cancer rates?"

[00:34:04]>> I don't think we understand it yet. I think with vaping, what you will see with vaping in a way that I had not seen with cigarettes is an acute lung injury.

[00:34:12]So, I have seen particularly young patients come in with vaping who have this very severe acute reaction. And so I do want people to be aware that that is a real problem. Um and that is a real possibility. I think with increasing marijuana uses or people being more open about their marijuana usage and vaping, we are starting to collect data. Um people are collecting data on how that might combine with tobacco exposure as well. But I don't know if we have enough data and enough longitudinal data to really say that the implications are the same. I will say I tell people I don't think you should inhale any of these things. I think all of them are probably not great for your lungs and I think we can feel pretty good about saying if you can stay away from that it's a better choice.

[00:34:56]>> Thank you doctor. And as you can tell here in New York the smell of marijuana is virtually everywhere.

[00:35:01]>> It's remarkable.

[00:35:02]>> I know. And now I mean I think about like on the street as I was running home from my lung CT scan, some guy was smoking and I was like sure I got to get away from any any secondhand smoking.

[00:35:12]>> That's how I feel. I'm missing half my right lung. I'm back to running six miles multiple days a week. If I start smelling smoke of any sort or see someone vaping, I like hold my breath and I try to run by. I don't I don't want any exposure.

[00:35:23]>> Don't want any exposure. All right.

[00:35:24]Kathy from Marlo, Connecticut asks, "If I swim in an indoor pool, do the fumes from the chlorine affect lung health?"

[00:35:32]These are like really interesting questions.

[00:35:34]>> I've always wondered that too. So, I'm going to look at Kim.

[00:35:37]>> I I don't know how good we have been about collecting that type of exposure history. I think you we talk about AI.

[00:35:42]We also talk about electronic health records and all of these types of questions that we can ask and all of the data that we probably aren't even asking the right questions. Zip codes are universally available for all of us, right?

[00:35:53]>> And asking questions about specific types of exposures. I think we just haven't asked a lot of these questions yet.

[00:35:58]>> I think this is the type I mean this is a question that's made for 23me is because the advantage that 23me has is that we get self-report data. So we just ask people questions all the time. So, what I can say is I'm going to take that back to the team and make sure that we're asking because I've always wondered that as well. It's like you're indoors breathing chemicals. Is there an impact with that? So, that's the type of thing we should be asking all of our customers. It's as a lung cancer survivor, people >> um at first I felt were blaming me for getting it. And what I've realized over time is they're protecting themselves.

[00:36:28]So, I get often not just do you smoke, but do you use hairspray? Do you use dry shampoo? Do you swim indoors? And I'm always like, I run outside. [laughter] Um, I run outside. I don't use hairspray or dry shampoo, but I run outside. I don't get a manicure. I run outside. Um, but I think it's interesting. I think like one thing you could say, we talked on about radon briefly. We have carbon monoxide detectors. We should have a radon detector. It is so easy to do radon mitigation. They just put a, you know, pipe under your house. It's very simple. There's uh libraries all across the country that have radon detecting devices. It's only a couple hundred, which can be a lot for some people. You can check it out of your library and use it for a couple weeks. Radon levels fluctuate a lot based on weather and time of day. So, if you can afford it, buy one and leave it in there.

[00:37:18]>> But it's not just radon, right? There's so many different pollutions we don't know.

[00:37:22]>> Yeah. Can you break down what exactly is radon? you were talking I mean it comes it's aerosolizes from the soil and that's one of the reasons that it is so variable depending on weather and rain and construction and and >> construction sites when you start to dig it can come up >> it's a carcinogen so in my book I um interview a few other survivors and um a common theme I found with some of them that felt that radon was the reason is they're actually personal trainers or big gym rats and they build gyms in their basement during COVID and they worked out there multiple hours a day and they found extremely high levels of radon. So that is because it's in the soil and under your house.

[00:38:01]Uh Natalie in Cooper City, Florida asks, "Is there a correlation between increasing exposure to chemicals in hair or nail salons?"

[00:38:08]>> Mhm.

[00:38:09]>> Yeah. And we talk about those types of exposures. Cooking oils is probably the one that's been studied the most because we do see this increased risk of lung cancer specifically in um Asian countries and Asian women without smoking exposures. Now, I will say there's a researcher in New York who has then repeated the screening in women of Asian descent and has found very similar cancer incidences where they're not having the same types of cooking oil exposures. So, even though again it's it's this combination of genetic predisposition and exposures, not everyone who's exposed to the same cause may develop the cancer. Um, so it's really understanding how do our genetics interplay with these exposures. And I think the research is going to help us.

[00:38:50]But I just want um what I was dealing with when people would try to blame me or figure out why, even though it's because I have lungs, maybe because I run outside, is that my mom is a breast cancer survivor. When she would tell people, I have breast cancer, her friends, the family around us, they cooked meals, they picked us up from school, they helped her. As I have gone through it myself with lung cancer, I don't get that response. the stigma around it is so negative that I get not how can I help you, I get what did you do wrong? And I think it's people's way of protecting themselves is how I've >> made sense of it. But it's fascinating.

[00:39:28]And so even as we sit here and talk about it, everyone wants to know, >> well, why and how? And we should and we need to figure that out, but we don't know yet. And so people are trying to make the right decisions like Susan did.

[00:39:42]She was a runner. She took care of herself. She did all of her right tests.

[00:39:46]>> You called it in the book. It's that some people call it a deserved disease.

[00:39:49]>> Yeah.

[00:39:50]>> That was so it seemed cruel almost that we judge people that way or would suggest that, >> right? I think >> I mean Kim talked about it. That's why it's decades behind in research because people thought of it as a deserved disease >> even as a funding. Yeah. you know like people it is the first question that people always ask and and you also have to get like for people who have smoked for a long time you know and having also lost my nephew to addiction smoking is addictive you know it's really hard like knowing people who have smoked like it's not a there's no such thing as a deserved disease like no one deserves to get lung cancer so even for people who were like smoking used to be recommended by your doctors like for people who have an addiction to smoking they don't deserve to get lung cancer and we addictive products.

[00:40:35]>> 100% we as a society have a responsibility to take care of those people and to understand like all these questions are completely valid like nail salons, hairspray, all of this like let's go we should 100% go and and study all the different exposures. We know certain things like radon you know has an impact and smoking obviously but we should be going and exploring and understanding others.

[00:40:57]>> Pam from Anchorage, Alaska asks, "Aren't these good questions from all over? How effective are lung screening exams especially for women who have quit but smoked during their adult years?

[00:41:10]>> Lotoct CT is a fantastic test. No screening test is without risk. And whenever we think about screening tests, we think about sensitivity and specificity. So sensitivity is what is the likelihood that we can find the cancer. Specificity is if we find something, how good are we at saying that this is cancer versus this is this is not cancer. So loto CT has a fantastic sensitivity. It's very very likely that if you have lung cancer, we will find it on your CT scan. The specificity is not as good. So we find things often that can mimic lung cancers. Infections is a really good example. Um that you know most often what we'll say is there's something here. Shar likes to say and and she's absolutely right. We have freckles on our skin. We have nodules on our lungs.

[00:41:51]So when you have your first CT scan, it's very likely that we may find a nodule, but we don't necessarily recommend that you go and have that nodule biopsied. with breast because the biopsy it's less invasive and it's an easier test. We are more accepting of lower positive findings with a breast biopsy than we are lung biopsies.

[00:42:11]>> So it's more likely that we'll say come back in a couple of months. Let's see if this nodule is changing in a way that makes us feel like it's more likely or less likely that this is cancer and then we'll make a recommendation for something more invasive. Now the hope is that with a blood test we could tell you that day you have a nodule but your blood test tells us this is very unlikely that this is cancer or this this is more likely so let's do something sooner but the test is excellent. It is important that you go somewhere that this is what they do and they're an accredited facility and the people ideally that are looking at these have looked at a number of them and know what these nodules look like and which ones are more likely or less likely to be cancer. Dr. You mentioned that lung cancer research is about 20 years behind other cancers in terms of that research.

[00:42:55]This podcast is about optimizing your health. And so this part is what's the biggest innovation that you're excited about when it comes to lung cancer. And I'll start with you Ann. I I I'm wildly excited about the potential for blood screening and having creating a truly sensitive and specific blood screen that can help people, you know, get a chest CT as well and understand whether or not that is actually cancer.

[00:43:23]>> How far away are we from that?

[00:43:24]>> Oo, I think I think in the next 5 years.

[00:43:27]>> I think early detection is very important. So that's where the blood screen comes in and hopefully within 5 years we'll have that. Today we have the lowd do CT. today our insurance um doesn't cover it. That's part of the reason I started my small foundation on the side called cancer doesn't care for all the money I make from the book to go there to pay for people's screens until we can. But I think what's important about the blood test that I'm hopeful for also is what it gives lung cancer patients a future as well. So for me today I'm on I'm not on any medication.

[00:44:00]So I'm on I call it aggressive surveillance plan. I get a blood biopsy every six weeks to see if my tumor is back and in my blood and I get a CT of my chest every 12 weeks and that's the plan for a few years and then we'll reduce it from there. What I'm talking about with the blood test for cancer patients is we have great medicine right now. So there's amunotherapy drugs, there's chemo drugs, different pieces like targeted therapy drugs and what we're finding with a lot of them is they work until they stop working and our bodies build up against them. I think it would be also amazing if these blood tests that can hopefully detect cancer very early could also be used for a patient that maybe is on an amunotherapy or a targeted therapy and as they see in the blood test that maybe there is no more evidence of disease they could taper off of these drugs continue to monitor them with the blood work and then go back on them if they need to because right now they're seeing a lot of these imunotherapies only last seven to nine years until our own body >> builds up an immunity against imunotherapy. drugs.

[00:45:02]>> I think for me as a radiologist, lowd doct saves lives. There have been a number of randomized control trials done in this country and all over the world.

[00:45:11]CT scans save lives by detecting lung cancer early. So my hope is that as we start to get more and more excited about the blood tests and we continue to invest in those that we incorporate CT imaging as well. And what's so unique about that opportunity is that we can save lives while better understanding the science and better understanding what early detection should look like.

[00:45:32]>> And so as we're doing that work, we can find people like Shira and we can find their cancers now. And because they're willing to be part of this, we can save lives while we are doing the research.

[00:45:44]No doubt there's a lot of preventative screening that's available now and it's just getting better because of a lot of the research and funding that that you are providing. This part of this podcast is called three simple things.

[00:45:56]>> Three Simple Things [music] is sponsored by United Health Group working to close the women's health gap.

[00:46:02]>> Let me just ask you Dr. Sandler. Um and we've talked about um you know sometimes this just happens because you have lungs as with many cancers. But Dr. Dr. Sandler, what are three things you can do to lower your risk of lung cancer?

[00:46:16]>> Yeah, I think if you do smoke, then I think absolutely quitting smoking is extremely challenging. There are resources out there. It is really, really hard. But it is not only your lung cancer risks, it is heart disease, it is other diseases that if you are able to quit smoking, that is one of the very, very best things that you can do for your health. If you do meet current eligibility criteria right now because either you smoke or you have smoked in the past, please go and get screened.

[00:46:44]All insuranceances that are ACA compliant right now should cover that without a co-pay. So please talk to your doctor and have that low OCT done. And then I would say a call to action to talk to the people you love, those that meet eligibility criteria right now. And also do your own research and and learn more about lung cancer risk. and we should all be advocating for an opportunity to find this disease early and my hope is that that is the direction that we are going. This is my thing about my dad is actually an infectious disease doctor and a preventative medicine specialist. And so I always think about how often we go to get our hair done or get our nails done.

[00:47:20]Although sure you don't get your nails done, but they look great. [laughter] But I think about how much time we invest too and for women too. You know, we see our OBGYn a lot with our kids.

[00:47:29]Like why aren't we doing that same kind of stuff when it comes to one seeing mental health experts but also just getting preventative screenings and the and the insurance industry and the government should support that because whether it's lung cancer or so many other things having regular contact with the physician can just improve our lives dramatically, >> right?

[00:47:49]>> I mean I think I'm very focused on health care, not sick care. That's what I always say. Take care of yourself when you're healthy and feeling good. It allowed me to run six miles the morning I did that scan, be told I have lung cancer, deny it for a few days, have half my right lung removed, and be back running weeks later.

[00:48:07]>> And I think it's cuz I've always focused on taking care of myself and advocating for myself and being healthy versus only running to the doctor when I'm sick.

[00:48:16]>> I mean, I think the reality is the health care system doesn't necessarily make it easy for you. And so just want to recognize like for a lot of people like a lot of people have come to me now and said like I want to get a scan or I want to do you know you you talk about like it's pleasant to go get your nails done. It's pleasant to get your your hair done. You know it's not always pleasant to have to show up to the hospital system and health care system.

[00:48:39]And so I do think >> Shira Shur's own surgery was denied.

[00:48:43][laughter] >> Yeah. I mean there there's so many crazy aspects here. And so it's just one thing I want to acknowledge with people. It's a fight. Yeah. But it's worth the fight.

[00:48:53]And so I think about I mean the reason why Sher and I came together to do this show and like to to talk to people is because the juxtaposition of the two of us here tells you the outcome. You know, my sister is not here and Shira is, >> you know, but my sister would be here.

[00:49:13]>> Yeah.

[00:49:14]>> If she had been scanned.

[00:49:15]>> Mhm. But we didn't know. Nobody knew.

[00:49:20]You guys know everything. I mean, brilliant, brilliant women. It just wasn't Nobody knew.

[00:49:25]>> I've known Ann since >> I was 20 and we were up to no good in San Francisco. And um I watched the Wajeski girls go through everything. Um and it was terrible. And that Wednesday when I got my pathology report that I had an adn no carcinoma and I thought I have to call an [laughter] I um I didn't know what stage I was. I didn't know if it would work but it was one of my first phone calls because I was like who's going to know this better? Who's been through this? It was just a year after Susan had passed and um it was terrible. And then as I did my own research for the and ultimately wrote the book and started working on my own advocacy, I was like, "Ann, we got to do this together." And she was building SWF and everything.

[00:50:16]>> What was amazing is when Shar called me and and I said I was like, Shar, we're going to be that story going forward together. Like the minute she called, I was like, "You founded early and you're going to be okay." And so like we will be able to change the world because of this. And so I do feel like that's like a big part of our mission now. Like health care and prevention is hard. So we recognize that for everybody, but if you look at what happened with like the HIV world and breast cancer, like look what Susan G. Kman did to change the whole landscape. And so there's an advocacy component. And so I think that's where I look at for anybody who has lung cancer, join the 23me lung cancer community. For anybody who's concerned, like go and fight and get your chest CT because it is a matter of life and death. And there are you can you you can catch it early and have like a normal healthy long life. And so just think of all the important things that you want to be there for like going and fighting that fight to get your chest CT. Like >> it's worth it.

[00:51:18]>> It's absolutely worth it. Like I mentioned, I've done this for over 10 years, and I have never been more optimistic and excited about all of the lives that can be saved and all of the positive that can come out of these stories. And it's time to say enough is enough. This has been the leading cause of cancer related mortality for men and women in this country for decades. And we now have an opportunity to change that. And we can not only make the research better and make the testing better, but we can change it right now because of what's available. And I think we need to focus on all of the amazing things that people will do after their diagnosis. Because if we find it early and they're cured, >> you have this entire life after a lung cancer diagnosis. And that's that's relatively new.

[00:52:05]>> There are two more segments of this podcast. This is the one where we say turn the tables, which makes me very nervous because I like to ask questions, not answer them.

[00:52:15]>> [music] >> So, do you have any questions for me?

[00:52:18]>> I want you to tell everyone about your scan this morning.

[00:52:21]>> You know, thank you so much because I've again I'm the only one in my family who doesn't have a science degree. You know, doctors in my family, my sister's a surgeon. This was not on my radar until your sister's death and your book. So, thank you.

[00:52:36]>> Thank you. And so I'm so grateful that I get got to go have this lowd dose CT scan which is so easy compared to a colonoscopy or a mammogram and luckily it looked clear. And then there was a bonus. They also looked to see if there was any calcium in my heart and um oh we looked a little bit at my thyroid so it was kind of >> bonus scan. Bonus bonus. It was like a bonus. So um I really agree with you.

[00:53:01]You know, I think these can be anywhere from about what, $450 to $1,000, but I know that people like you are trying to reduce that cost for people because now you would have to pay out of pocket for it. You know, it's interesting. When I had mine um done at Vanderbilt in October, it was $777.76.

[00:53:20]And I remember that cuz they called and said, "Your insurance is denying it.

[00:53:23]We've canceled your appointment." I said, "Please don't cancel my appointment. I'll pay for it." I know it's $777. And she said, "And.76." I said, "Got it." And 76 cents. So I did that through the process by uh in January. By January, Vanderbilt had reduced it to $450 cuz I'd worked with them. And in April, they they got down to just over 200. There are ways around this.

[00:53:45]>> I will say Shira's first scan was a diagnostic study because we knew that there was something there.

[00:53:50]>> So there the LDOS chess CT is excellent and it is similar to a diagnostic, but yes, the LDOS if you look nationwide can range from about 150 to usually about $300, $400. So good. For cross-sectional imaging or advanced imaging, it's much less expensive than an MRI or maybe other procedures that you would pay for, but it's not nothing, which is why we need to continue to to make it more widely available.

[00:54:12]>> The the calcium score that you got, often people get that test all the time and they pay out of pocket. And I always say that's a picture like this. We're just going to make the picture like this. It's the same scan. or just a wider lens so that you get your entire lung in the view, a little bit of your thyroid, a little bit of your upper abdomen, too. So, I think it's important. It's an easy scan. The prices is, I think, about $150 to $300. Um, that's part of the reason I started cancer doesn't care is to cover people scans until we can get insurance to do that. my website also because we talk about a lot of times going and asking your doctor for the scan and it can be a battle because you're not over 50 and smoking a pack a day for 20 years.

[00:54:54]>> And part of what I have on my website too is print this page because when your doctor tells you no, tell them this.

[00:55:01]When they recommend that you're not in the guidelines, say this. And it kind of helps you walk through it because we have to advocate for ourselves because like Kim said, we not only need to educate our peers, but we need to educate the doctors and from the top down, we need to change the guidelines.

[00:55:17]>> And I guess that's actually my question for you. Did you have anyone tell you, I really think this is a bad idea. You don't meet eligibility criteria. You should not have this test.

[00:55:26]>> No. No. because I think that that's pretty >> that has come but that has come up in the full body >> MRI scans and the idea that there are false positives that can result from that. So that has come up certainly. Um there's another test that someone wants me to get where I have been counseledled like that's really unnecessary and it's just expensive like why you don't need that. But again these are based on statistics you know what I mean you're the out you know you need to decide I'm the outlier right so um but not in this particular case yeah and I wasn't going to say no to Shira [laughter] >> even if no one says no to shar >> even if they told me you know it's not a good idea you don't need one. And I said, "I'm sorry. Shar told me [laughter] to go get one. I'm going to get one."

[00:56:09]>> Yeah.

[00:56:10]>> Our final segment is called And if You Remember, Nothing Else.

[00:56:17]>> So, as people have been listening to this, you guys have taught everybody so much. Thank you so much. And shared so much of your personal story. So, but if you remember nothing else, what would you want people to know? Doctor, >> I think lung cancer is a curable disease when we find it early.

[00:56:33]>> Yeah. And we need to change the perception of what lung cancer is and what lung cancer means and what that future looks like. And the more work that we can do to allow for early detection, the better because it is a very curable disease when we find it early.

[00:56:49]>> Go get your lowd dose chest CT like Norah did this morning and Ann's done and I've done and Kim has done and that's what we have today. So go get your lowd dose chess CT. Advocate for yourself and catch yours early if you happen to have it too. Mhm.

[00:57:02]>> I think the things that are most important is for people to realize like lung cancer is the number one killer and cancer killer and it's import it's a crisis and so we all have a responsibility and activism. I think second what's so critical for me is changing the narrative of preventative screening not as something that people are afraid of like oh I don't want to find out if I have cancer but rather that people say I want to have the opportunity to live.

[00:57:26]>> Yes. So preventive screening needs to shift from the fear element to an opportunity of of of life.

[00:57:33]>> Yeah.

[00:57:34]>> And so that's where I want people to stop having that fear and recognize that all of your screening is that opportunity for you to actually be there for your grandchildren and to have the life that you want.

[00:57:45]>> You can have more control.

[00:57:46]>> Correct.

[00:57:47]>> It's empowering to deal with disease that happens. Disease happens. I think my be all end all goal with everything is to make cancer a chronic illness we die with not from and that's how I feel and a lot of times breast cancer survivors are doing that HIV has become that and let's make all cancers that >> well um you guys are my heroes I really I'm really so proud to know you proud to know your sister incredible woman incredible mom and sister and everything so all that she did so and I thank you all and thank you all really for sharing so much information because as you point out it is a health crisis that is not even on anybody's radar. So thank you. Thank you. Thank you.

[00:58:31]>> Thank you for having us.

[00:58:32]>> Thank you.

[00:58:35][music]