A Welcome to the IUPUI Center for Translating Research into Practice monthly conversation with our scholar of the Month. My name is Stephan V Weeg. I'm the Associate Director of the Center. It's my pleasure to welcome you here and get the whole thing started today by sharing my screen so that you can see what we're all about. Today, we are going to be welcoming and talking with doctor Kathy Mosher, who will introduce in just a little bit and her community partner, Donna Pope, who're going to lead us through a conversation about a very interesting topic. But we have to start by acknowledging our founding partner here at the Center for Translating Research into practice, doctor Sandra Petrono, who had the brain child to set this into motion. Doctor Petrono, is an internationally known scholar who has done a lot of research on the area of privacy management. And when she and her husband, who happened to be our former chancellor, Charles Banz came to campus, She noted that a lot of the work that happens at I EPY here in Indianapolis is very community engaged and focused on solving problems in the community. And so she said, this is the most translational place we've ever been and said, we have to promote this, we have to identify this kind of research and encourage others to do it and take note. Charles Banz is our executive director now, who is leading the charge and continuing this plan and supporting our work in helping folks here at IPI connect with community partners and to help solve our complex problems in the community. So we're glad that you're here today for this conversation. We have these every month. Hopefully, everybody's familiar with Zoom now, but just a reminder, While at the beginning, to go ahead and leave your microphones muted, but please turn on your cameras, and we hope that you'll leave your camera on and that you will unmute when there's a chance for us to have a conversation to ask questions and talk with each other. You're welcome to put your comments and questions in the chat as well, and we'll help moderate that and share those with doctor Mosher and her community partner. If you'd like to share, this presentation is being recorded so that you could share it with others in the future if they weren't able to come, and we promise that we will send you an e mail afterwards today asking you for your feedback about this event. So please take a moment fill that short survey out to let us know what you thought and give us ideas about upcoming events, speaking of upcoming events. You can check our website always to find out what's happening, and you might not know, but you can get continuing education units for attending these monthly sessions. There if you visit IU expand, you can learn more about that and sign up. There's lots of ways to keep up to date with us. You can follow us on Instagram. If you'd like to see the other videos that we have on our YouTube channel, please check us out there. And, of course, you can follow us on Twitter and go to Facebook to find out more about what's happening. If you go to the website, though, we encourage you to go visit our featured scholar page. For example, you can go there and Find doctor Kathy Mosher today, and you could see a little bit more about her work as an explanation, but an exciting feature is that you can see her journal publications that are listed in Scholar work. There's a couple listed right here on her page related to her work. But if you click on her link to the IUPI Library Scholar page, you can see all of her works that are easily and accessible to you at no cost. You could also go to the trip collection of the IUPY Scholar workors, and see the amazing amount of work that is there and available for you to see at no charge. We have these events every month, so we encourage you to check us out. Next month, we'll be talking with drum roll please, doctor Lisa Staton, who will be talking about the Diabetes Impact project. And that will be next month on the 11th. We're doing it a little bit early because of the holiday seasons. And we also, if you're interested to know, we host an information session about some of the Banz awards. There's a Avance Petronio Trip Scholar Award. There's also a Bans Community Fellowship Award. If you're a faculty member interested in learning more about that, please join us for either one of these sessions. But today, we are delighted to have with us, doctor Kathy Mosher, who's at IEPY in the School of Science and focuses her work on clinical psychology. Today, her topic is to talk about supportive care for adults with a dad's cancer and their family members. A topic that many of us may have some personal connection with and she's also invited her community partners. So we are delighted to have you here, and we're going to ask you to Well, I've lost my screen here. So we're going to ask you to go ahead and unmute and get yourself going here. And I got to find? Where did it go? Yeahre, it is. So welcome, Kathy. Thank you very much for the introduction. I'm delighted and honored to be here today. As he said, I'm a clinical psychologist, and I've been conducting research in the area of symptom management and quality of life and cancer care at IPI for the past 12 years. So for the scientists in the audience, this is not your typical research talk. I'm going to try to stay away from statistical jargon as much as possible. This talk is more about the intersection of personal and professional journeys. So first, I'll describe a bit about why I entered this field. Then I'll present one study that my team conducted, followed by a Q&A session with you all. Then Donna will share for about 10 minutes her personal journey with metastatic cancer. Then you'll have a chance to ask Donna some questions. And then I hope to present a second study that my team conducted and will end with a Q&A with Donna and me. So again, there'll be three Q&A times. I encourage you to put your questions in the chat or to mute yourself during those times. But first, I want to share with you all why I entered this field of study. Oh, share my screen. Oh, yeah, I will share it once I say this. Thanks, Stephen. So I first encountered cancer as a 14-year-old when my mother was diagnosed with incurable cancer that had spread to almost every bone in her body. Over the next six years, I would watch her undergo many rounds of chemotherapy, radiation, and experimental bone marrow transplant. And through this journey as a teenage caregiver, I became increasingly aware of the profound suffering that so many patients and families experience with this disease. A key lesson that my mother taught me was how to live life to the fullest despite the fact that one is dying. And this is indeed the focus of the psychotherapy that I test in my intervention trials. So now I'm going to present just a one question poll, if Nori could please present that to the audience. Your response is anonymous. You could just answer yes or no and submit your answer, and then Nori will show the results to everybody of this poll. Okay, so 94% of the audience has either had a close family member or friend with a cancer diagnosis or they themselves have been diagnosed with cancer. That is not surprising to me because we know that 40% of men and 40% of women in their lifetime will be diagnosed with cancer, according to the National Cancer Institute. And in 2019, according to the National Cancer Institute, there were close to 17 million cancer survivors in America. Believe it or not, 2022 was the first year that program officers of the National Cancer Institute attempted to count the number of people living with advanced or metastatic disease. And that number was over 620,000 in 2018, and that only included the six most common types of advanced cancer, not all the different types. And of course, that number will only continue to increase as medical advances continue. Okay. So now I will share my screen and talk about a trial that my team conducted. Can everybody see that, okay? All right. So the form of psychotherapy that I test is called acceptance and commitment therapy. And this trial that I'm about to present enrolled patients with metastatic breast cancer with the primary outcome being the degree to which symptoms interfere with functioning or mood, cognition and activities. So first, briefly, a bit of background. We know that symptoms are a major problem in metastatic breast cancer, and I list some common symptoms there on the slide, that they often interfere with important activities. We also know that effective interventions are lacking, especially for the most troubling symptom from the patient's perspective, and that would be fatigue. Researchers have not found effective medications or behavioral approaches to managing fatigue. And with regard to behavioral interventions, group therapies focused on emotional disclosure or traditional to behavioral techniques have only produced small short term improvements in pain and distress. So there really is a need for interventions with this population. So acceptance and commitment therapy, otherwise known as act has a different focus than traditional cognitive behavioral therapy. So traditional cognitive behavioral therapy focuses on symptom reduction. Whereas act, it's a slightly different focus. The focus is, how does one move in the direction of one's personal values and live life to the fulest despite the fact that one is experiencing symptoms. So to break the cycle of symptoms interfering with functioning. It does this through increasing awareness of the present moment, including thoughts, feelings, and symptoms. So a compassionate awareness, I might add, and also helping patients to take small feasible steps in the direction of their personal values, whether it be spending time with family or their spirituality, for example. And in small preliminary trials, this intervention has shown promise and reducing symptom related suffering in patients with cancer. And this intervention was originally tested in patients with chronic pain and those with mental health conditions with some beneficial effects. So here's an example of an exercise that encourages patients to attend to the present moment. This is a focus on the breath. This is otherwise known as mindfuless. Some of you might be familiar with that term. And the idea is that this interrupts more maladaptive responses to symptoms such as catastrophizing or assuming the worst possible outcome or rumination where patients worry excessively about symptoms. They can see that they're told to attend to their breath in accepting compassionate way. And here's an example from our intervention of identifying values. So that is not an exhaustive list of the values, but to some of them. So patients are asked to rate these domains on a scale from one, not at all important to them, or up to ten, extremely important. And then they rate the degree of effort that they're putting in those domains during the past week. And often there's a discrepancy between what they say is important and the effort that they're putting forth in certain domains. And that's an aha moment where they can begin to set feasible goals with the therapist to pursue their values. And pursuing feasible goals is very important among patients with advanced disease because often they tend to overexert themselves, and the therapist can help them set more manageable goals. So the aim of this pilot study was to examine the feasibility of delivering this phone based interventions to patients with metastatic breast cancer and to test the effects of this intervention on symptom interference with functioning. And we compare this intervention to what we call education support, which I'll describe in a minute, but it controlled for time and attention given to patients. So we recruited 47 patients with metastatic breast cancer. All of them had to have at least one moderate to severe symptom. And here's an overview of the study flow. Everything for this study took place over the phone. Patients were screened for eligibility, completed an initial assessment, and were randomized to six weekly sessions of act or six weekly sessions of education support. And then there were follow ups at eight and 12 weeks. So I already discussed the focus of act. I want to add that patients were instructed to engage in home practice each week where they practice mindfulness and pursued their goals in the direction of their values. The comparison condition was called again, education support. This is similar to the types of interventions that social workers deliver every day in cancer centers. Patients were oriented to their medical center. Variety of quality of life concerns were discussed, and they were provided with contact information for medical center and community resources to address these concerns. They also were given tips for evaluating health information available online and in other formats. Our feasibility indicators were enrollment and retention rates, and we also administered standardized assessments of symptom interference with functioning. In terms of our results, we achieved a solid eligibility screening rate, especially for this population, with 100% of eligible patients consenting, and we also had strong retention rates. So as you can see, we did not find improvement in global symptom interference or pain interference in either study condition. However, we noticed that the green bar would be the Act group, and the blue bar would be the education support group, that in the Act group, although they started at a higher level of fatigue interference than the education support condition, that it was trending in the right direction, that it was declining. And we also saw a decline in the Act condition in sleep related interference, but we did not see much change at all in the education support condition. So our results suggest that Act is a feasible intervention for this population when delivered by phone, and our enrollment and retention rates were above average compared to literature with this population. We speculate that perhaps decreases in fatigue and sleep interference with functioning for patients in the act group may be a result of increased mindfulness and adaptive behaviors aligned with their values. I want to note in terms of interpreting the pain interference findings, the patients had low baseline levels of pain, so there was little room for improvement. There are also some shortcomings of the global symptom interference measure. It just referred to symptoms without defining what that means, and it only referred to the past 24 hours, that might have limited the measures ability to detect change. Limitations are the small sample size recruited from one medical center and limited racial diversity. As a next step, we have a large scale trial of the intervention to determine whether it's effective, and we've enrolled over 90% of patients with a strong response rate, although it did vary across study sites and a stronger than expected retention rate. And I'd like to acknowledge all my collaborators on the pilot study informing that large trial, as well as the Walter Cancer Institute and excuse me, Walter Cancer Found and National Cancer Institute for their support. So I'm going to pause there for questions about this study before introducing our next speaker, Donna. So again, you can place questions in the chat if you prefer or feel free to mute yourself. And please also turn on your cameras if you're so interested so that we could see you if you might have a question. So are there questions or comments for doctor Mosher about what she's shared so far. Doctor Bans? Just very specific. I was surprised the low level of pain, was that a typical of the population that metastatic stage four? Yeah. I mean, I've noticed having done research at the Simon Cancer Center now for over a decade that often pain levels among patients with advanced disease are, you know, in the mild to moderate range. And I think it's because pain is well monitored at the cancer center and patients are given effective medications in many cases. So I think that is specific to the Simon Cancer Center. But I think if I had done a study across various sites, it would be a different outcome. Okay. So the quality of the air intrusiveness isn't the right word, but the vigilance. Because that surprised me. All right. And it sounds like a message is that it can be managed. So that's a thing, right. And are you see in the larger study, the same thing with the levels of pain? Is that the stud the study is also based in Simon. So the larger study, I'm recruiting at various IU health sites. I'm also recruiting various community health sites, and I'm recruiting at a site in Chicago. So I would expect more variance in pain. I haven't looked at the data at this time, but I would definitely expect more variance as socioeconomic status also greatly varies across patients. So I think that's a reasonable hypothesis. It looked like from your graphical representation that some of the interventions you were doing had worth showing a declining trend, but when you got to the eight week period, it wasn't it looked like it took an upturn. And have you considered about sustainability? Is it that the intervention needs to continue during care, that it doesn't carry over its effective during care, it looked like there may have been an uptick at the eight week and 12 weeks, so an impact but not sustained. When the referring to. So it looked like if you could pull us. Sure. Side up, that would be helpful. Yeah, I think so too. Okay. So you're talking about this? Yes. So look like when you you know, what struck me was that for the fatigue. Yes, that was being maintained after the intervention stopped at six weeks. For the sleep related interference. It seemed to be holding steady. But it shifted at the eight week marker or post intervention for the global symptom interference and for pain interference. There was a shift there for in the direction of improvement. No. No, but there was a change. I just want to the Sorry. Go ahead. D need to interrupt you. No, I've finished. Okay. Yeah, so this education support condition, although, you know, patients can certainly bring up their concerns, and if they say they're in pain, we strongly encourage them to talk to their doctor or nurse. That's the extent of the intervention. So I'm guessing that that's just normative. I mean, with treatments with other conditions of the small pilot study, there's some normative fluctuation in pain. I don't think that's a very powerful intervention. The education support condition for pain. Though you can argue referrals are important. But yeah, I think that's a normative fluctuation. Does that help? Yeah. And I guess your larger study, it's really important for that to kind of see what happens when you're looking at a larger population across different institutions. Mm hm. Absolutely. And I'll be curious to analyze by site and perhaps sociotic status as well. Okay, Donna, you can turn on your video if you want. Okay, great. And you can unmute yourself. So I'm so delighted that Donna Pope is joining us today to talk about her experience with metastatic cancer. I just asked her to share a bit of her personal journey with us, and you'll have the opportunity to ask her questions right after her talk. Good morning, or I guess this afternoon by now. My name is Dona Pope, and I am a 17 year cancer survivor, the last 4.5 years being metastatic. So I was initially diagnosed back in 2005. I have no family history of breast cancer. I have no risk factors. I thought I had covered on my bases. I had my babies before 30. I breastfed. I did all the things that are supposed to give you a better chance of not developing breast cancer. But I had discovered some dimpling in my left breast back in 2005, we were on a vacation in Panama. And I thought I'd just put that on the back burner and I had a mammogram scheduled for June. And so I thought, I'll just wait for that rather than go in in advance. So I waited and I went in, I had the mammogram. Then the lady came back in and said, the doctor wants to do a sonogram, and then she came back in the third time and said, he wants to do a biopsy. So that was all done in one day and I went from thinking it was going to be a routine exam to finding out I had breast cancer. So I received a call at work, and it was quite a shock to find out that it actually was breast cancer. I had no idea how You know, 17 years later, I have lots of ideas about types of cancer, stages of cancer and how that leads you to treatment. But I was immediately sent to see doctor Getty at Community North, and he said that he wanted me to go and see doctor Jennifer Morgan. So she has been my oncologist since day one. And so I started that journey. Doctor Getty suggested because the tumor was 4 centimeters in size, which was fairly large, that he wanted me to take eight chemotherapy treatments. And then I would go back and see him to see if the chemotherapy had shrunk from the tumor or So I had the eight courses. I had Adri Myosin Cytoxin, which the nurses referred to as the red Devil because it's kind of a harsh treatment, and then I had four treatments of taxol. So some of my side effects were loss of hair. And with the taxol, I had numbness in my fingertips and my toes and I know now that doesn't sound very major, but at the time, it was quite scary because just to step off of the curb, I wasn't sure my feet were going to hold me. So I got through that and then after Christmas I finished that in November of 2005. Then I waited till January had my surgery, which doctor Getty said I could qualify for a lympectomy with radiation. So that was my course of treatment. Then I had 33 radiation treatments following the surgery. And those were relatively easy for me. I would stop by every morning at 8:00 and have my 15 minute radiation treatment and would go on to work and I felt fine. And at that point, after my radiation, my hair started to grow back. You know, I started to get my energy back. I felt really good. So then 11 years goes by, and we were on a trip to Hawaii. And my back was hurting tremendously. And I thought it was because I had been doing a lot of standing on my feet. I was helping out a couple of my friends by working retail, which I've never done before. And I was working and standing on cement floors and things like that. So I attributed the pain to just being on my feet too much. So we went on this trip and I'll have to admit it was not pleasant. I was in a lot of pain. It affected my appetite. I just I just felt horrible. It was the first time I'd ever come back from a vacation eight pounds lighter than when I went because we also took a cruise while we were in Hawaii and there was lots of food. So I came home and I called my doctor and said, Wait a minute. I've got to back up. After the after the trip to Hawaii, I Sorry. I have to consult my note. It's been a long journey. And I always tell people, hey, I've had brain brain radiation. I get a little confused at times. So in 2017, So 2005-2017, it was smooth sailing. I had my monthly or my yearly visits with doctor Morgan. And then in 2017 went for another managram, and it was it came back positive for stage zero, but it wasn't the same cancer as before, but it was in the same breast. So I met with doctor Candace Ludwig was my breast surgeon, and she said that I had to have a mastectomy because I was I had had the maximum amount of radiation with my lumb ectomy in 2005, so I couldn't have that again. And at my age, she said, you want to make sure that you cover your basis with effective medication. So I had a double mastectomy, and then I I had reconstruction at the same time. It was a 13 hour surgery. I'm not sure I'd do that again because I had a deep flap. Where they took the tissue from my stomach and grafted it into my breast after the mastectomy. So I had a bilateral mastectomy and I guess it was after that point that we were on our vacation and I started developing the back pain. The back pain. I called my plastic surgeon that did the deep flap because it was in the area of the breast reconstruction, the pain that I came home with. So he said, let's get you in some physical therapy. So I did three weeks of physical therapy, which was excruciating and not pleasant. And then just by luck, I had my yearly physical with my regular doctor. And I was so weak by that time. That my husband went with me to my physical and doctor Cornett said, Donna, I'm not liking what I see on your on your blood work. He said, You liver enzymes are just out of control. He said, I'm going to call doctor Morgan right now. So he did, and she was able to see the results on the IU portal. And she said, I want to see you tomorrow in my office. So we went in and She told me at that time I had metastatic breast cancer. And so my husband and I are both fairly optimistic people, and we just looked at each other and we said, what do we do? So she told us that we would we would start a lot of testing. There were all kinds of tests that I did, I did. I had CT scans. I had a nuclear bone scan. I had a brain MRI. I had also some kidney problems. She said I had a lazy kidney. And so she wanted to schedule me to get a stent in that. All of these things turned up stage four metastatic cancer. And doctor Morgan has just been an angel. She has known how to relate to me and to my concerns. And she said, Donna, you'll be so amazed at the advances that we've seen since 2005. So she immediately called in favors from her doctor friends and I was that whole week. I was in for all these different tests, and just it was remarkable how quickly everything moved. But My husband has just been a wonderful support system for me from the very beginning. I mean, he took over the grocery shopping. He's retired. We're both retired. He took over the grocery shopping, the cooking, the caregiving. During my bilateral mastectomy, I developed a terrible infection and he had to play nurse. It wasn't pleasant and so he's been a wonderful support for me. And this last 4.5 years dealing with metastatic cancer has taught me that for me. And this is strictly for me that I don't think beyond today. I enjoy today. I get up thankful. I have a strong spiritual life. I'm a Catholic Christian, and I've said a lot of hell, mays in the last 4.5 years. And I have a lot of people praying for me, and there have been many ups and downs in this last 4.5 years where I'll think, Oh, it's going well, and then boom, something else happens. I've had four gamma k three gamma knife procedures to my brain. Most recently, this past summer was told by my radiation oncologist that he was kind of at the point where I was developing new lesions and the chemotherapy doesn't cross the brain barrier, the brain blood barrier. And so I was feeling pretty gloomy about my future. And then two days later, doctor Morgan called and said that she had found a new drug. Well, it's not a new drug, but it's a new drug for my type of breast cancer. And It's a targeted therapy, and I go in every three weeks for treatment, and it has shown remarkable results since July. My cancer markers have gone from over 3,000 down to 900. So I'm moving in the right direction. And I just think with My husband, being my number one cheerleader and caregiver has been tremendous. I have four children. We have four children, and their support has been greatly appreciated. I have a group that I belong to through my church. They have been so tremendously supportive with prayer groups and rosaries and all that. I've been very fortunate in that respect. I'm happy to say that I am living every day to the fullest. Yes, I'm tired. Yes, some of it's unpleasant, the treatments and all, but I really feel blessed but I have the support system I do and all the advances in the medication for breast cancer. It's just amazing. When one doesn't work, doctor Morgan moves me on to another, so I'm very grateful for that. And that's my story and in that show. 17 years, condensed into 10 minutes. Thank you so much, Donna. That was an incredible story. I'll now pause for any questions from the audience, either in the chat or you can mute yourself. I have a question for you, Donna. Okay. So I'm sure everybody in the audience wants to be, very supportive to people, you know, with cancer. And for you, what specifically has been besides the prayers, and what specifically has been helpful for you in terms of support? Just being able to talk about it. I don't want anyone to ever feel uncomfortable about it. I have a very good friend that I've spoken with many times during this journey, and we can be very up front and talk about, Well, what's the worst thing can happen? Well, the worst thing that can happen is I can die. And it might be tomorrow. It might be ten years from now. But you have to face that reality. And I think I don't want people to ever be afraid to say, how are you doing or how what's your prognosis? I have to explain to people, you know, my treatment won't end. My treatment will go on until the end of my life. So, That's something. I think that has brought me a lot of comfort as being able to talk about it. Yeah, and I'm sure it's sometimes confusing for people like, why? Doesn't your treatment end? And the other one that patients often say is, well, you look so well, right? In the discrepancy between how you appear versus how you feel. Exactly. Exactly. I don't look sick, I hope. And that is confusing to people. I think they think I'm going to be just laying in bed all day. So I try and keep my life as normal as possible within bounds. I mean, I can't walk as far. We went on a Disney trip in May, and I had to take my breaks, but hey, I was there, and I was doing it. So that's my way of coping. Any other questions for Donna? Donna, I'm curious if you do you connect with others, any support networks around to talk about those issues with others? Well, a very good friend of mine. She actually recommended me for this. Her name is Cindy Day, and I met her through the American Cancer Society Volunteer Program Ride to Recovery, where you sign up and you take people to their medical appointments if they're unable to drive or if they don't have the transportation available to them. And I met her and we have met over the years for breakfast or lunch. And she's also a metastatic breast cancer survivor a couple of years longer than I have. And she's just a tremendous person, and she gives me a lot of insight into what's worked for her, and we bounce those things off of one another. Mmm. So that kind of supports someone who has been there and done that. So it's been very helpful to me. And Donna, I would love or ask a question if you don't mind. Sure. Yeah. So my name is s, and I actually know Cindy Day. So is a S a small world, right? Yeah. So, Kathy and I are always looking for our next research idea. And I wonder if you could share with us kind of what you're hearing on the street from your, other breast cancer survivors in terms of the greatest sources of suffering, that we need to find really good interventions for. Do you have any tips or ideas for us for our next big study? Oh, gosh. Well, I'm thinking. I guess, just to stay involved in In what helps comfort you and what leads you down the path to being okay with this diagnosis because it's a heavy diagnosis. And, you know, my husband and I both pray that the researchers out there who are doing fabulous work will sooner rather than later find that cure, and every day I hang on, my hope is that you, we're one day closer to a cure, not just for breast cancer, but for all cancer. So I would say, just I pick up a lot of information when I go in for my treatments. There are patients sitting on either side of me in the chemotherapy chairs, and we talk. We talk about our diagnoses and our ups, our downs, and all that. So that in itself is a support group for me. And then just being able to talk very frankly with doctor Morgan has been wonderful. She's just like I said earlier, she's an angel. Really. So, Donna, are there any things that have been particularly challenging for you in this? When you might have to ponder that, but are there any aspects of your experience that you think, gosh, that was really super hard or it would have been easier if something happened. And that might be a way for us to think about, like, well, where could the rest of us be helpful around exploring ideas that could make things better in that experience? I think one of the hardest things for me has been missing out on some activities. Just due to fatigue, or then when COVID came along, my suppressed immune system. I missed some family weddings, I missed some graduations, some big family events, and that was really hard. Probably the hardest thing through this whole ordeal was, you know, telling the kids that I had a life threatening disease. Metastatic breast cancer, that would be something that I would not want to do again is to call make that call. Our children all live out of town. So had to make those really tough calls and face their fears and assure them that, I was determined to fight this, and I think that is something that would well be addressed. I just how to deal with breaking this kind of news to those who love you and Sometimes I think it's harder on the people that love you. I think it's harder on them than it is on me, sometimes because it's just it's hard. If I had to deal with that being on the other side of the table. Yeah, that'd be hard. I think my husband internally moles over my diagnosis and doesn't always express his anxiety, but, you know, it's something to deal with. Yeah, there's a lot of research to back up your point, Donna. I mean, my team has examined family caregivers of people with cancer and this is a population level data, found deficits in mental and physical health outcomes compared to non caregivers. In the interest of time because I know we only have a few minutes remaining, and we are going to I'm sure Stephan will make sure we log off early. Instead of presenting, because I won't have time to present my second study, I'm going to present sort of my vision and future directions, and then maybe, Donna, we could talk offline about different research ideas. You could help me make sure certain things. So I will pull up kind of a future direction slide. So I have a large grant proposal under review to test the same intervention that I introduced to you. Only it's with both patients and their family caregivers. So thank you, Donna for leading me to my next research direction. It's with family caregivers. It was a perfect introduction. We found some promising results in a small pilot study in terms of the intervention's impact on fatigue interference with functioning in patients with advanced gastrointestinal cancer, and caregiver burden or the negative impact of caregiving on their lives. And so I'm excited that Grant got a good score, and I'm resubmitting that proposal as we speak. And Shelly Johns, who you all met, and I are talking about other research ideas, more than talking, we're working on the proposals. And one intervention is a mindfulss based intervention to help people cope with the emotions associated with advanced care planning. It's another important activity that people with advanced cancer do, as well as to improve their quality of life. And right now, we're also have a grant under review That is a descriptive study leading to a study that combines acceptance claim and therapy techniques with financial education. Another key problem among people with advanced cancer is financial toxicity. In other words, many people experience bankruptcy or have difficulty paying bills, or they might lose most or all of their savings. So how can we help them regulate their emotions, have the education they need and cope with those significant practical concerns? So that's some of my future research directions. And I want to thank Donna again for being so courageous to share her personal journey with us today. Yes, thank you both. For taking some time and chatting with us and letting us ask some questions and help inform what's next. And as a reminder, we are committed to respecting your time and officially ending our time here at about 10 minutes of the hour, so that those that have the afternoon activities have time to get to that place. We want to thank you for joining us today. We will, however, stay online for a few minutes for those that want to have the after the session time to maybe share a comment or a question with either Kathy or Donna. Reminder, just in a couple of weeks, we'll do this again and on November 11, earlier in the month than usual, but we'll be talking with, as you can see here, doctor Lisa Staton about the Diabetes impact project. And please follow us again in any way that you can share information, but always we're always looking for ways that we can connect community partners, scholars, students, staff, people together that are interested in solving complex problems by generating or using knowledge that helps us to figure things out. So congratulations to our folks today. Thank you for participating and giving us a lot to think about. We will officially end our time now and let those go that need to go. But we will stay on for just a few minutes for those that want to stay.