Force2010

Breast screening - before and after preventive surgery

This session was supposed to cover only the post-surgery bit of the equation, however the presenter spent some time covering surveillance pre-surgery (if that's the path you choose), which will be of interest to those who still have breast tissue (as opposed to stomach fat on the chest or some other variation of new-boobs..)

There were no slides provided, and Dr Levin presented a whirlwind of information in rapid-fire form. So apologies for any lack of detail in this follow up.

Dr Elsie Levin, a doctor specialising in diagnostic radiology, talked about the limitations of mammography vis MRI, which is extremely sensitive. She said that women (with breasts) at high risk of breast cancer, especially those under 50, should be having annual MRIs as the density of breast tissue in this age group makes it so hard to read mammograms. She did, however caution that we should be looking for somebody specialising in breast MRI, and suggested asking the question 'do you do MRI guided biopsies?' to test their experience level. How practical this is from an NZ perspective might be another thing altogether.

She described the track record in clinical trials of mammograms for high risk patients as 'abysmal'. An early Canadian study of gene carriers showed that while around 30% of cancers were picked up by ultrasound and mammography, 70% were seen on MRI. She was quick to point out that technology has improved since then and that the detection rate with MRI was now up to 95%.
For the most impact, she suggested combining MRIs and mammograms, and regardless of whether your breasts are dense or not, if you're a gene carrier (her words) you need annual MRI screening.
She also talked about 'cancers that don't look like cancers' unable to be seen on mammogram but showing on MRI.

Post surgery, she says there is no evidence for routine breast screening at all.

After mastectomies, she says, lumps grow in the scar line, and are clearly seen and felt.

And:
"You never find a lump on MRI after reconstruction that is not found by clinical examination. The recurrence rate is so low and occurs on the surface of the breast. If we do an MRI following a flap reconstruction, the chances it will show anything are just about zero."

That's another $1,000 a year that can stay in my back pocket. My health insurance won't cover the cost of post-surgery MRIs. I'll put it towards the next FORCE conference...

Screening after surgery - ovary removal

Those of us who have had risk-reduction surgery, whether it's prophylactic mastectomies, oophorectomy or both, face an uncertain decision when it comes to surveillance afterwards.

While we do reduce our cancer risk significantly it's never possible to get it all the way down to zero because it is impossible to get every last cell at the time of surgery.

What to do after surgery is a difficult question. And advice seems to vary wildly, depending on who you talk to. Some of the more honest doctors might even admit that they just don't know what to do with us - we're such a recent phenomenon.

Dr Robert Burger. a professor of surgical oncology, outlined what is known about ovarian/peritoneal surveillance after oophorectomy, and left attendees with a practical roadmap for monitoring moving forward.

He started by outlining the effectiveness of oophorectomy. While historical studies (those looking back on people who have had the surgery) show a risk reduction of up to 90%, prospective studies (research projects that follow people from the start in a controlled way) have that number as low as 80-85%. Dr Burger said the real number is probably something like 90%, on average.

The concern after oophorectomy is 'ovarian like' peritoneal cancers.These can happen for a variety of reasons, including microscopic disease already being present in an ovary of fallopian tube and traveling after the ovaries are removed, missed diagnosis of ovarian cancer at the time of the surgery, or the surgery missing bits of ovaries or tubes.

The fallopian tubes are becoming more important to researchers looking for causes of ovarian cancer, with increasing evidence that it may start there. Early ovarian cancer is often detected in the fallopian tubes of women with BRCA mutations.

Dr Burger told us that while there is insufficient evidence to support a post-surgery monitoring strategy, it is very reasonable to have one, and it would make sense that early detection could improve outcomes. Women who have had oophorectomy still need to be aware of the symptoms of ovarian cancer and see a doctor if they have symptoms more than twelve times a month, and if those symptoms have been present for less than a year.
Things to watch out for are pelvic or abdominal pain, urinary symptoms, feeling full or having difficulty eating, increased abdominal size or bloating, negative affect (bad moods) and depression.

While ovarian cancer is notoriously difficult to pick up in its early stages (by the time it is found it is usually well advanced), Dr Burger says CA125 tests can be useful for women post oophorectomy - especially since peritoneal cancer can show as a subtle elevation in levels.

He cited a UK study (Jacobs et al, Lancet 1999) that looked at almost 22,000 women (in the general population - not specifically high risk) aged under 45. The participants had their CA125 levels checked each year for three years, a pelvic ultrasound if levels were elevated, and a referral to a gynaecologist if that was abnormal. They were followed for 7 years.Four hundred and sixty eight women in the screened group had abnormal CA125 levels, 29 had an abnormal ultrasound, 6 were found to have cancer. Another 10 cancers were found during the 7 year follow up.

The women who took part in the screening programme lived 31 months longer than those who didn't. While some of this may be explained by 'lead time bias' (the cancer being found earlier, so it looking as if women were living longer when, in fact, it was just that their cancer was known about longer), Dr Burger said it didn't explain the longer survival time completely.

His recommendation for high risk women post oophorectomy:

While there are no studies reported, no evidence supporting the approach and no published consensus, he still suggests we are better to be safe than sorry and combine a CA125 test with a physical examination every year. Despite the very poor prognosis we have come to expect from this cancer, he says 'not every stage 3 is the same', and he is hopeful that earlier diagnosis can make a real difference to outcomes.

New thinking on exercise and lymphadema

The second part of Dr Kathryn Shchmitz's session focused on the effect of exercise on lynphadema.
Patients who have had breast surgery with lymph node involvement have long been cautioned against lifting heavy weights for fear of causing or worsening lymphadema.

Dr Schmitz and her team set out to discover whether weight bearing exercise did, in fact, make the condition worse. Their surprising finding was that it can be beneficial for lymphadema sufferers - provided they take the slow, steady route under careful supervision.

Dr Schmitz used the (very American) analogy of snow shovelling and heart attacks to explain why. Just the way that heart patients unused to vigorous exercise land in Emergency Departments every year at the start of snow season, so lymphadema patients or those at risk of developing the condition bring it on when they find themselves in a position where they have to lift a heavy weight. By avoiding weight bearing exercise all that time, they have made themselves even more vulnerable to the very thing they are trying to protect themselves against.

Dr Schmitz's research participants underwent a supervised strength training programme that involved slow, steadily increasing weight training. Results published in the New England Journal of Medicine in August 2009 showed that lymphadema flare ups needing treatment were reduced by half in those who took part in the programme. In those who did have episodes, the symptoms were less severe.

A soon-to-be-published paper details a 63% reduction in the risk of lymphadema onset amongst the strength training group.

"Women undergoing breast cancer treatment who are at risk of lymphadema should all be getting a prescription to go to a personal trainer,"Dr Schmitz said.

Hang on to your uterus, gals

If it was possible to clutch a uterus for dear life...that's what the attendees at Dr Carol Fabian's Early Menopause and Hormones session would have been doing.

This 30 year veteran of breast cancer research and oncology had some pretty clear views about the usefulness of the uterus after childbearing, and was firmly in the 'rip-em-out-once-you're-done' camp.

It was an uncomfortable eye opener for those of us whose surgeons had only gone as far as ovaries and tubes, and you could almost see a collective 'whaaaaaat??' thought bubble forming over our heads.

So why take things that step further? It's a bit technical, so bear with me. Dr F did a fantastic job of making it all make sense in the session, but my medic-translation skills are challenged by this one.

According to Dr Fabian the safest HRT is the estrogen-only kind. But taking estrogen on its own bumps up your breast and uterine cancer risk. And so the need to add progesterone or progestin to the mix to reduce THAT risk. But progesterone/progestin bring another set of risks of their own. And so on and so forth.

Confused? You're not the only one. And don't think you're safest just to do away with the hormones altogether if you're a young woman contemplating (or in) surgical menopause.

Dr Fabian's bottom line is that, despite the increased cancer risk it brings, estrogen is essential if you are going to remove your ovaries very early, as it protects young women who wouldn't otherwise be menopausal, against a raft of other serious conditions that can develop as a result of it - heart attack(84% increased risk(, cognitive impairment (46%) and Parkinsons Disease (68%).

She says that the evidence shows that eight years or less of estrogen-only use (which you can only safely do without a uterus) doesn't increase breast cancer. And even COMBINED HRT (the kind you take if you are unfortunate enough to still be with-uterus)may lower the risk of death across the board, despite bringing a small breast cancer risk.

Just how big is that risk?

Well, here's a reality check. And a very interesting way to look at what can be very confusing numbers.
Using a combined hormone replacement therapy (estrogen plus either progesterone or progestin) increases breast cancer risk in the same amount that two drinks a day does. And even that elevated risk disappears within a few years of stopping HRT.

For women with major risk factors - the BRCA 1 and 2ers - Dr Fabian says the additional risk that HRT poses is next to nothing, when you compare it with the 20-fold increase the genetic bum-card deals them. Imagine a bar graph with whopping great bars for BRCA risk (at 20) a bar half that size again for Lobular Carcinoma in Situ, and 'AH+FH' (whatever thay may be), a '7' sized bar for AH only and then teeny, tiny almost imperceptible blips for obesity and alcohol use (scoring a 2).

So why the worry about HRT?

I'm not sure I've entirely got my head around it, but I'll do my best.

First off, there has been a great deal of conflicting evidence in this area and loads of very heated scientific debate that's been going on for three decades now. Study after conflicting study has come out with great fanfare, and then, for one reason or another, been shot down. That's without even getting started on all the politics so rampant in womens' health issues. Everybody is confused - doctors and patients alike.

Then there's the relative newness of the whole BRCA/HBOC phenomenon. They just haven't been able to study us long enough to come up with definitive answers.

Then there are all the inherent contradictions and confusions of HRT that are hard to for everyone to get their heads around - the protective effect against heart disease and stroke in young menopausal women, for example, turns into an attack in older post-menopausal women (it's to do with whether you have plaque buildups in your arteries or not). And the weirdness of some of the evidence - that while it can increase breast cancer, the overall death rates in women taking HRT are lower (something to do with a reduction in symptoms leading to fewer accidents etc - interesting!).

In the same vein, Dr Fabian did quote from one 2008 study called HABITS (HRT in breast cancer survivors) that found that while there was a 22% increase in new breast cancers within 5 years for those high risk women in the study taking HRT (8% of those not taking it developed new breast cancers), there was no difference in survival between those taking HRT and those who didn't.

Dr Fabian's final words were that HRT isn't a no-no (or contraindicated, if you prefer) for higher risk women - especially if it's ERT alone, and that those undergoing prematured menopause under 45 should consider it - whether they are symptomatic or not.
She also says the type, dose and route of delivery can lessen the health risks. ERT plus or minus testosterone is better than combined estrogen and progesterone. Progesterone is better than progestins, low dose beats moderate, and patches or vaginal delivery is safer than oral.

So what's a girl to do?

Well, if I was to do it all over, I'd push to dump my uterus along with the rest of those bits I no longer have a use for. But that's just me. I'm not going to line up for any more surgery, but if they're in the neighbourhood anyway, any time in the future...that's another whole story.

I'll definitely be talking with my endocrinologist about transitioning to a patch and having a conversation about the progesterone/progestin thing. It'll be a fun conversation, doctors just love it when we front up with a heft of somebody elses conference slides. It's right up there with an internet print out.

Exercise may one day buy time before ovary removal

Oophorectomy is a brutal - but sure fire - way to reduce breast cancer by up to 50%.

But it's not for everybody. And even those who undertake the surgery don't enter it lightly, needing time to work through their options.

Dr Kathryn Schmitz's session focused on the impact of exercise on breast cancer risk and the risk of recurrence - two key areas of her research.

While most of her work is focused on the general population, she is presently recruiting for a study that will shed more light on the impact of exercise in women at high risk of developing breast cancer. And her research may one day offer those contemplating oophorectomy a reliable way to keep their estrogen levels low enough that they can safely buy some time before having their ovaries removed, if that's the path they choose.

Dr Schmitz gave us a rapid fire overview of the evidence around the links between estrogen and breast cancer, and talked about the impact of exercise on estrogen levels, as seen in elite athletes, whose levels drop so low that they no longer have periods or ovulate.

Estrogen levels have long been linked to breast cancer risk. The famed Nurses Health Study, one of the longest running and most respected women's health studies ever conducted, showed that women diagnosed with breast cancer have estrogen levels 10% higher than those of women free of the disease. More than three dozen studies over the years have shown a 30-40% reduction in breast cancer risk in post menopausal women who work out vigorously for more than three hours a week.

Four studies looking at the impact of exercise on recurrence risk have come to similar conclusions. Combined, they show a 44% risk reduction in women who are physically active.

But just how to reliably achieve a reduction in breast cancer risk through exercise, and how big a reduction in estrogen levels is needed, are things that nobody can say for sure at this time.

Kathryn Schmitz's WISER (women in steady exercise research) study is a four year research project that hopes to answer questions like these. It looks at how exercise impacts two key things thought to promote the development of breast cancer - estrogen levels and oxidative stress - in 400 women aged 18 to 30.

A companion study, WISER Sisters, is looking specifically at high risk women. This is the one that will be of most interest to Gift of Knowledgers, as its findings may offer those at high risk of breast and ovarian cancer a natural way to reduce their estrogen levels, and in turn, their breast cancer risk.

"There have been no prior studies in women at high risk," Dr Schmitz told the conference. "We don't know how much exercise it takes."

That's one of the questions participants in the Wiser Sisters study will hopefully answer. Those taking part are sent treadmills that they get to keep after the study is over, assuming they go the distance. They are asked to either walk on an incline or run for 150 or 300 minutes a week. Their estrogen levels are measured at points along the way.

Seven out of ten women who took part in a pilot study finished the programme. All did the 'high dose' 300 minutes a week. The results were encouraging - a 40% reduction in estrogen levels was noted in one woman. The average was a 21% decrease in estrogen levels.

The full study is looking for participants now.

Dr Schmitz was quick to point out that exercise is not a panacea, and that nobody is suggesting that physical exercise is more powerful than genes or environmental factors. However physically active women who get cancer do come through treatment in better shape.

And exercise has been proven to help with pain management, fatigue and tiredness and quality of life. To a lesser extent, symptoms and side effects are reduced, and exercisers report improvement in 'vigour and vitality'.

Counter-intuitively, depression and anxiety in cancer sufferers are unaffected by regular, vigorous exercise.

In physical terms, exercisers report strong improvements in cardio fitness, physical activity levels, strength, flexibility and something called 'immune parameters' (I'm sorry - even Wikipedia couldn't give me an easy definition. More persistent googling might shed some light on it for you. Presumably this is about how strong your immune response is, but I'd hate to make a wrong assumption. Should've asked...). Weaker - but still significant - improvements are seen in increased muscle mass and lymphedema avoidance.

Speaking of lymphadema...anyone who has had breast surgery involving lymph nodes will have heard that lifting heavy objects is something they need to avoid, sometimes for the rest of their lives. Dr Schmitz turned this notion on its head in the second part of her session.

More on that one to come...

And Again...

So I was planning on writing up my notes from the conference sessions over the few days between getting home and heading back to work.
I'd deliberately taken this week off work to make sure I had a slow, quiet transition back to the real world - especially since this whirlwind trip came so close to my surgery, which was only 8 weeks before we left.

Best laid plans and all that...
I ended up not going home at all, and instead hopping a flight to Queenstown as soon as my feet hit the ground in Auckland to come to work here for the week. You don't even want to know how my 30 degree celsius wardrobe is working in Winter Festival Lans. Let's just say Glassons' Merino Sale is working for me.

In the spirit of this entire extended trip I nearly didn't get here at all - our flight was diverted to Dunedin due to ice on the runway and fog. Sat on the tarmac there for an indeterminate length of time chowing down on plane snacks and killing time (they wouldn't let us off the plane because all the security screeners had gone home) before they finally got us in to Queenstown below the cloud.

Still, a better deal than that facing the occupants of an ATR sitting on the runway beside our plane. They ended up bussing across.

So I'll be slow in writing up these notes, but I'll do the best I can to get them out as fast as I can, because I know some of you are going to be really interested in what's going on.

Up in the air again. Again.

Just gotta keep telling myself, think of the airpoints...
It's a five hour flight now to LA, and I've gotta tell you, I need every minute of that just to let my brain rest after a whirlwind 2 days.

Nearly all of the sessions were outstanding. One was frustrating, as the presenter veered from the topic in the programme only to rush through it in 5 minutes at the end. One was a bit wiffly-waffly and badly structured. Two were jaw-droppingly good. None were just plain average.

I took so many notes it's going to be hard to know where to start, but I will attempt, over the course of this plane ride, to get as much down as I can.

The conference really drove home some key things for me:

1) things are changing all the time in this field. There's lots that is new, and it is by no means an issue that is standing still

2) there are really clever, dedicated people here on the other side of the world devoting their entire careers to BRCA and HBOC (hereditary breast and ovarian cancer) issues. They find it hard to get their message about advancements out to their own colleagues, in their own country. Let alone to clinicians half way around the globe. We need to keep ourselves informed and take the information home to be looked into and filtered by our own health care providers. Those can be hard, awkward conversations, but they need to be had.

3) one million Americans are BRCA positive. On top of that are the families impacted by
HBOC issues. That's a powerful number. Here in NZ (if I've got my math right) it's going to be in the tens of thousands. If that. Some GPs might not even have seen or identified a BRCA or HBOC patient. We see generalist gynaes and generalist breast surgeons, and are sent to them by generalist GPs, all of whom will have wildly varying understanding of the issues. That seems to be often times true in the States, too, from some of the conversations I had with other women at the conference. But at least there are evolving centers of excellence here and serious research going on, and growing advocacy and awareness.

4) there is hope. Real hope that 'they' will understand so much more about the grey areas of HBOC and BRCA. More and more is being understood all the time. And I have real hope that they WILL find a better solution than scooping out breast tissue and chopping out ovaries, by the time my daughter is old enough to worry about this.

More later...

PS I'm sorry about the weird formatting. It's because my ridiculously indulgent ipad doesn't like the blog software. I have to wait till I land and unpack my laptop to outing line and para breaks etc.

Day 1

There are more than 530 delegates at Force 2010, so it's no surprise that I've yet to find K, the other Kiwi in the room.
K, if you're out there, I'm wearing a green and yellow paisley frock and an apple green cardy. Can't miss me.
So far it's only been opening remarks, but they've set an optimistic and hopeful tone. And it's inspiring to be even in the same room as some of the leading lights in this field, the equivalent of BRCA and HBOC medical rock stars. What is really encouraging is the deep, personal passion they have for this area. And coming from NZ, where there are so few true specialists in this area, their depth of knowledge and commitment.
I've worked in and around health for years, and it's rare to see such harmonious and respectful linkages between the medical community and what is, essentially a consumer group - testament to the respect that FORCE has built and the integrity it has maintained over the years.
Dr Tom Sellers was the most interesting of the opening speakers from my perspective. He's part of a group of clinicians and researchers from around the world who have thrown out the old model to find new ways of making advances in ovarian cancer diagnosis and treatment. He talked about how the old way - individual scientists working in isolated groups - fostered competition and stymied progress. His group has taken a strategic and deliberate approach to breaking down the barriers, essentially forcing cooperation and collaboration by staging twice-yearly face to face meetings, coming to an agreement about not 'scooping' one another with research, and centralising testing and other services to specific centers of excellence. In an area that can so often feel hopeless (ovarian cancer being almost impossible to diagnose early enough to change its course significantly), he was a real beacon of hope.
Speaking of which, the woman sitting next to me for that session is a 17 year breast and ovarian cancer survivor. Seventeen years! She was stage 3 on diagnosis but she's still going strong. Hopefully people like Tom Sellers will one day be able to find out why people like Cathy do so well. And bottle it for the rest of us.
Up next for me is a free genetic counselling session (yeah, yeah I know they want to sell me a multi thousand dollar test, but what's to lose? And I'll leave my credit card safely locked up in my room...), then after lunch the sell-out session After Surgery. Now What? Which I am especially interested in, since I'm having little luck in getting consistent answers at home about what, if anything, I should be doing, now that I've removed my body parts. Later, y'all....

Up in the air. Again.

En route, New York's La Guardia to Orlando. So here's ironic. I had to wait 'til I the aircraft got to 10,000 feet to post this leg of the trip. Despite 4 hours of waiting at the gate and another hour and a half on the Tarmac, the airport wi-fi wasn't going to play ball. I was lucky to get off the ground at all - I've been rerouted via Atlanta (but upgraded to First Class, so at least I am inconvenienced in style. If you can call it that, here). Then an electrical storm whipped through the airport just as they were closing the doors to the aircraft, resulting in what the captain described as 'the worst meltdown we've seen at La Guardia in a long time. There was thunder and lightening, the plane shook and shuddered like crazy (I don't think it felt any better in 1A than down the back, sadly), the rain pelted down and the ramp and ground staff beat a hasty retreat to safety, grinding the whole airport to a halt, and leaving planeloads of us trapped in little tin cans scattered across the runway. Comforting. The storm passed as quickly as it blew through, but left the 'meltdown' in it's wake - an aviation traffic jam of New York proportions. We finally got airborne after 1.5 hours of crawling along the runways, stopping every so often for 10, 15 or 20 minutes at a time. After 5 days in the Big Apple I'm ready to head south. As fun as it is, a girl can only take so much of the noise, the heat, the people, the traffic, the queues, the incessant honking of horns and whine of sirens that ARE New York in the height of Summer. Who can blame them for packing up and escaping to the Hamptons? We had a few meetings of our own in NY, but we were also tagging along with another couple- friends - this trip. The husband was attending a breast pathology conference, funnily enough, getting up to speed with all the latest diagnostic developments in the field. There's so much that's new, all the time. I read again, in a mag I bought at the airport bookstore, that one key health agency (others are still debating it) over here no long recommends breast screening for women in the 40-50 age group ('normal' women, that is, not BRCA or HBOC-ers), and scarily, they no longer recommend breast self exam or even doctor exams, for anyone. I say scary, not because I think we should be prodding and palpating ourselves pointlessly, but because we put our faith in these things for so many years, somehow reassuring ourselves that they would keep us safe. Or safer. Only to be told there wasn't any point after all. I was trying to explain to my pathologist friend at dinner how vulnerable it makes you feel for the goal posts to keep shifting. I don't think he got it. But what I do know for sure, is that I've never been happier to be without 'real' breasts than right now. There is still so much they just don't know. And so much uncertainty. Anyway. Enough for now. We'll be touching down in Atlanta soon, they'll whip my wif-fi out from under me any minute. It'll be a quick dash to gate whatever-is-next to make the connection to Orlando, and I'll make my final destination just in time for the opening drinks. Let you know how it all pans out. trip. Ironically, the husband was attending a breast pathology conference, keeping up withe

On my way!

So here I am, blogging at 30,000 ft, fully connected to not-so-shabby wi-fi, halfway between Los Angeles and New York. Surreal. It seems like the last bastion of Internet-free peace and quiet is finally crumbling, with airlines selling broadband coverage here for just $16 for the duration of the flight. My heart sinks a little at the thought of my email-free bubble finally being burst - the thing I love most about working out of town is being able to be truly, utterly, irrevocably Unreachable, no guilt, no excuses. 

Still, there are advantages. I got completely messed up about timezones (I'll live across four of them this next week, including home) and forgot to check my email before we left for the airport this afternoon. My sleepy, schleppy Sunday mood came crashing down at the realisation it was Monday lunchtime already at home. So nice to be able to log in and put an end to the 'what am I neglecting' anxiety. 

So here's the plan. Four days in NY to catch up with some work contacts and do as much of the Big Apple as we possibly can before zooming south to Orlando for the FORCE conference. FORCE is the US based inspiration for Gift of Knowledge (www.giftofknowledge.co.nz), the keeper of all things BRCA and HBOC (hereditary breast and ovarian cancer) related, from a consumer perspective. FORCE has grown to be a powerful influencer over the years, working also with the medical profession, media and government to raise awareness of the issues, advocate on behalf of those impacted by BRCA and HBOC,and educate a whole raft of different audiences. Importantly, FORCE provides a connection point for people wanting to know more about BRCA and HBOC and connect with one another - something that can make the difficult decisions we face significantly less fraught. 

The FORCE annual conference is a gathering of some of the most credible players in the business - and an opportunity to learn about the latest developments in the field. I'm one of two Kiwis heading to FORCE. I'll connect with K, an Aucklander who is also headed there, the night I arrive. As the Gift of Knowledge counts down to its own conference later this year, it's going to be good to see how it's done Stateside. Just as interesting will be the opportunity to compare and contrast. 

We have our own very unique NZ culture evolving around the difficult issues of navigating the minefield these familial cancers bring. One of the things FORCE does so well for its members is to shine a light on the path ahead for those just starting on the journey. There is something comforting about hearing the experiences of others who have been there before and come out the other side. The NZ patient experience isn't a carbon copy of the American one. The steps we go through approximate it, but we have added dilemmas of our own, as well as some we don't face, too, thanks to the safety net of a fully funded public health system - as patchy as access can be from time to time. 

So I'll be at FORCE and I'll keep you posted. First session 9am Thursday morning Orlando time. That's God-knows-what-hour-Friday-afternoon your time.