H: Mai Davies, Host
V: Vickki Harmer, Clinical Nurse Specialist
J: Janice Monk

H: Hello welcome to the healthcare show which is brought to you today by Lifeafterfive.co.uk, my name is Mai Davies and today we are talking about suffering from breast cancer. If you have suffered from it, are suffering from it or maybe you are in remission or perhaps you are caring for someone with breast cancer then this is the show for you. I am joined in the studio today by Vickki Harmer a clinical nurse specialist for breast cancer at London’s St Mary’s Hospital and Janice Monk who was diagnosed with breast cancer 6 years ago and has a very positive story to tell about living with the disease. Janice we will talk to you about your story in a moment. Vickki we are here to talk about new support that is available now for people suffering from and surviving breast cancer, this new website, tell us about it?

V: Absolutely I think it is launched today at www.lifeafterfive.co.uk and it’s essentially a website for people once they have got to their 5 years post diagnosis, perhaps on completion of treatment. It is an extra resource that people can pick up on really and also their family and relatives. There are spaces where then can go and get ongoing support. There are little vignettes of course which Janice is one of the five -

H: We can have a look now at the homepage. What will people first see when they go and look at the site? What will they find?

V: Well it is quite easy to steer yourself around the site. You can go on to the various pages depending on what suits you if you like. There is the Life After Five, which is the real focus of the website, which talks about on completion of 5 years of treatment what you do then and then there’s is another huge part of the site is also for people on diagnosis. So it really is talking about what breast cancer is, what the signs and symptoms are, and all the different treatments, going right through surgery to chemotherapy and going on from there really

H: There’s lots of, you know – it’s called lifeafterfive and there are themes of various things of five. There is one page I noticed which was very interesting called “five facts”.

V: Yes absolutely. I think it is trying to catch on really, I mean sadly there are no guarantees in life although we know that 8 out of 10 women do survive breast cancer. There are sadly no guarantees so it is just to be vigilant because I think over half the amount of – now I’ll get this wrong for sure – over half the amount of cancers that come back, come back in women who have had 5 years of Tamoxifen, so 5 years post breast cancer treatment. So it is really important to be vigilant. Look for signs and symptoms. Be breast aware, you know, check what is normal for you and of course any anxiety go along to your GP or your specialist centre, or again look up this information on the website.

H: Ok just quickly while we are still talking about this site just to tell everybody at home this is interactive so if you have got any questions for Vickki or for Janice go to the bottom of the screen in the box, put your name in there and your question and we will try and get them answered a little bit later. One of the pages I notice is personal experiences Janice, do you find with a page like that, that will be useful for people to read about other peoples stories; people like yourself?

J: Yes I do think it is very useful, because at the time when you are diagnosed, initially you don’t speak to anyone because you are in shock, but then after that you need people to speak to and it would be great to speak to people that have had life experiences. You have got your nurse to speak to or your oncologist who have not experienced it. Although obviously they discuss a lot with all their patients, but they haven’t actually been through it themselves. I think it is quite important to read people’s stories if you don’t know anyone who has had it.

H: Also on the site there are ways of finding more information; you can send for leaflets, is that right Vickki?

V: Absolutely you can in fact download them also. I mean there is a section on various information and leaflets that you can download, so if you haven’t got internet access at home say for example, you can go to a café download the information and take it back. Or also you know for partners or carers, children, you don’t know - the whole sort of gamut who are affected by one persons breast cancer journey really. There are also other patient support groups, where to go, other charities, internet sites and what they specialise in. So there is a whole wealth of information just brought together in that one website.

H: Janice tells us what happened to you because you were diagnosed with breast cancer 6 years ago weren’t you?

J: Yes.

H: And it obviously was a terrible shock.

J: At the time it was.

H: It would be to anybody.

J: Yes of course. I discovered it myself because I always check my breasts and a lump -

H: As we should all do.

J: Yes we should do. I was just aware because years ago I had had cysts after giving birth. So I was aware of my bust anyway. I checked it and went straight along to the GP who then referred me to the hospital. I then had a scan and a mammogram. I have to think back now to 6 years. I was then diagnosed with breast cancer which obviously was a big shock. In the beginning I didn’t speak to anyone. My husband and then my family and they were a big support to me. Not everybody has a supportive family which I was lucky enough to have, friends and family to support me. So therefore I think a site like this, if you feel you cant speak to someone, at least you can go on to the site and you can then get the pamphlets off etc. and read about it.

H: It is obviously important to have support from other people and to speak to other people who have had the experience that you are going through because obviously when you are diagnosed, for you, it is the first time you have ever gone through it.

J: That’s right

H: So it must be very useful to read about other people.

J: Well I think so. I think it is important to read – as you say – read about other people who have actually gone through it or are going through it and it is their life experience. So it is not just someone who hasn’t actually been through it.

H: It must have been quite difficult for your children. How old were they when you were diagnosed?

J: Yes my daughter was 19 and my son was about 13.

H: It was a big shock for them.

J: A very big shock because obviously when you first hear cancer - am I going to survive? That is the first instinct. It must be for anybody. Then after that you get through that and you have to be positive about life. I carried on every day basically.

H: You carried on working.

J: I carried on working and I worked throughout. I am still working.

H: What do you do?

J: I am an account manager for a fashion company.

H: You found working really helped you stay positive?

J: I did yes. Everybody was very supportive around me and the company I was working for at the time were fantastic. Everybody did support me. But not everybody has that support and I think it is important because all I could get from the hospitals was pamphlets. My nurse was fabulous but then she hadn’t been through it either and I just think something like this website –

H: So a site like this –

J: Yes I just think it is just wonderful. I really do because everything is there.

H: Excellent. Well we’ve got some questions coming in already, because people are very eager to speak to you both. We’ve got a question from Janet and she wants to know “is this site for sufferers or for families as well? Our mother is currently on the Tamoxifen course.” Vickki?

V: For everyone really. Actually, which I think is one of the beauties of it, I would suggest that she feel free to log on, to read the personal stories, you might get something from that, certainly the information leaflets, and also the more medical prose in it, no I think it’s for both really, it’s all encompassing, it’s for people who have the disease, who are fighting – you know getting through the treatment. Also for people after treatment and for family and friends –

J: It gives you all the information about the support groups

V: Yes

J: So if her mother wanted to speak to someone, you know there is a support group there for her

H: because it’s not just the person whose got the disease whose going through it –

J: No

H: It’s the whole family –

J: That’s right

H: Everybody’s kind of going through this together aren’t they and –

V: Absolutely

H: And support each other. Got another question already from Sarah who wants to know “does this site enable you to chat with other cancer patients? I think putting fellow sufferers in touch with each other is essential for mutual support?”

V: There isn’t a discussion zone at the moment, I think maybe in the future that’s going to be put into place, I think they wanted to launch it first. Certainly there are other charity, main charity websites, I know Breast Cancer Care has got sort of a discussion zone, there’s one for – their Lavender Trust for younger women and there’s one for their older women. There’s also a buddy system where they’ve got a whole database where they can, you know ring up for telephone support from one person to another. I run a breast cancer support group at the hospital, at St Mary’s where I work. I think we’re very lucky. There are also many complimentary therapy places where you can go, you can have massage, you can have a chat with others, you know and yes I’m sure it’s the strength –

H: Did you find that Janice, did you use support groups?

J: I didn’t actually use support groups to be quite honest with you, because I did have as I say a very supportive family and work wise everybody was –

H: So you were lucky

J: I was very lucky but as I said also there’s not everybody that’s so lucky, so these groups are there for you, so you should go out and contact them

H: Ok. Yvonne wants to know, “I didn’t realise there was such a high risk of recurrence after the course. Why is this and are people warned before they start the medication?” Vickki?

V: I think it’s difficult when you talk about risk and you have to talk about an individual’s risk, and that is you know totally different and sort of person specific in the way of what sort of cancer they’ve had removed, if they had their lymph nodes with cancer in them, if their cancer is sensitive, you know to having these hormone therapies, and this big Herceptin, if they can have Herceptin, if it’s HER2 positive, there’s no end of different things which you can work out in a way your risk of cancer coming back. It is a shock that it can come back, you know it is this high percentage that it can come back, despite all the treatment, so I think it’s just – not to be doom and gloom but just to say be aware, be aware if you have had breast surgery, say for example, the – you know what the scar looks and feels like, you know just to be aware of what –

J: Because they don’t actually tell you in the hospital all these things, you’ve got to ask all the questions the whole time, that’s why also this website there are things – you know you can read about it and you don’t always know the questions to ask at the time. I used to go away and then write them down and then go back to ask them. They don’t always volunteer you the information so –

H: So when you look on the website there’s things – “oh I never thought to ask that” would be very useful to you

J: Yes definitely

V: Absolutely and then you can go back and find out, I would imagine you know how that relates to you as it were

J: Yes

V: But I think there’s such a huge range of information and on the whole research says that communication between doctors and nurses and people going these sorts of things –

J: You know because you’re all individuals, you’re all so different, it’s like anything that happens to you in life, everybody is different, but if you’ve got a question you’ve got to ask it and if you can’t you can go on there and look – and there’s support groups

H: Got an anonymous question now from someone who wants to know “is Tamoxifen still the wonder drug or should patients be asked to be put on alternatives?” Because you were on Tamoxifen and another drug, you were on a trial weren’t you Janice?

J: Yes

H: What were you on?

J: I was lucky enough to be on the Femara trial which is Tamoxifen and letrozole. letrozole, initially, if I’m right was for more advanced breast cancer, but they’re trialling it aren’t they? They’re trialling it to see if it will be –

V: Yes – letrozole, there’s – Tamoxifen is the gold standard, the traditional 35 years I think it came out in 1970, it’s very good

H: It’s the one everybody associates with breast cancer

V: Absolutely and it’s the one, and I think it’s certainly the only one if I can say at this point, the only one that’s any good for pre-menopausal women. Once you pass the menopause there’s this new range of drugs called the Aromotase inhibitors which are Femara, Arimidex –

J: That’s what I was on as well

V: Yes and exemestane – they work slightly differently and there’s many trials, there’ve been many trials about whether to have two years of a Tamoxifen and then switch to three years of these Aromotase inhibitors, these different class of drugs, or whether if you have say the Femara up front before surgery, or then it extended so say you have your five years of Tamoxifen and then go on Femara again it decreases your chance – you know your risk of recurrence so there’s many ways for these drugs to be used, it’s - it gets quite complicated, I’m so aware not to – I confuse myself at times!

H: It must be very confusing for people who’ve got breast cancer –

V: Yes

H: Who, all these drugs –

V: Absolutely

H: Drug names are thrown at them

V: All of these drug names, exactly and the thing is just to really sort of find, so – what are the – and as I said, write them down, what of these are suitable for me, is this one suitable, when – you know what does current research say, and of course using the NICE guidelines

H: Ok. Mrs Eldridge wants to know “how often should I get tested after I hit the five year mark?”

V: Depends really on local, on her hospital policy. Some places do them, mammograms, every year, some places do them every two years. After 10 years some will put her back into the NHS for the screening program, so it really depends on the protocol at the specialist centre where she was treated

H: What would you say if somebody were to say to you, and you don’t know where they live, you know, how often should I get tested?

V: Yearly or two yearly mammograms I would say

H: Yearly or two yearly, ok. Alison wants to know “what do you think that most women who have survived for five years from breast cancer don’t do now that they should be doing?” Either of you?

J: Well I think that what’s being said now is that people aren’t aware that it can return –

H: Come back

J: So don’t after five years think that’s it, that’s fine, I’m in remission, you have to think that it could come back. As much as it can go to anyone else it can come back, so still be aware, be aware of your body and changes in your body. And anything, I would say, just phone your GP, don’t worry about phoning your GP. If you haven’t got a good GP then go back to your hospital. I’m sure most people – because I’ve been under a fantastic nurse, I’m sure you can phone your nurse up and they’ll just say come back, I mean I’m going back every year, I’ve just finished the drugs – 2 weeks ago actually

H: Vickki are there other things people don’t do?

V: Yes and I’d also say you know, live life! Exercise –

H: Are people too frightened to live life afterwards, do they become timid or –

V: I don’t know that you can say – I think it goes, we’re all so different aren’t we? I’m sure any ache or pain, quite rightly so, you think oh my goodness that’s the cancer coming back, de de de – but I think you know others say that it just flips on this whole positive side of life, and that you prioritise –

H: Like it did for you?

J: Yes

V: And so I’d say eat well, eat a well-balanced diet, exercise, keep your weight within the normal limits, keep positive, you know cherish yourself, treat yourself as you would others –

J: Do get on with life, don’t think about it every minute of the day if you can. That’s how I cope with it

H: That’s very good advice. Keep those questions coming in. if you want to ask a question of Vickki or Janice we’ll try and get them answered for you. There’s a box at the bottom of your screen, just go to that, type your question in, give your surname and we’ll try and get them answered in the next few minutes. We’ve got another question from Kate, she says “I am not as confident about my body after my lumpectomy, is there someone I can talk to?”

J: Well I had a lumpectomy, I must say yes, initially – see it depends there are all different types of lumpectomies as well, ok yes I am scarred, but I don’t feel too bad about my body myself

H: It didn’t knock your confidence?

J: It didn’t knock me totally, no it didn’t, so I’m sure there are support groups that you can go to, if you look on the website, there are support groups for everything and I’m sure you would be able to talk to other people that feel the same way that you do

H: Do you find that perhaps maybe sometimes younger women have their confidence knocked more?

V: Yes I was going to say, I mean it’s – to be honest all that sort of sexuality, femininity, body image is difficult enough anyway I think, before you’ve had this potentially life-threatening and body-changing treatment. I could suggest that there’s certainly I mean for one Breast Cancer Care who’ve got a good website, have got a great booklet on sexuality, body image, and also one on younger women which I think they encapsulate younger women being pre-menopausal, so I don’t know whether Kate’s that, or isn’t, I’m sure there’s no hard and fast rules – anything goes, basically there’s no rules. Also they do have as I said this buddy system, where you can join up, you say what your priorities are and your age and they try and match you with someone, and you have telephone support so you know my priority is talking about or looking at my scar, or not feeling that confident, you know and hopefully hook you up

H: There’s also the clothing isn’t it, not just lumpectomies but perhaps mastectomies, because I know that you helped a large retail store to design swimwear for women who’ve had a breast removed, because it’s important to keep the self-esteem isn’t it?

V: Absolutely, absolutely, and why shouldn’t they – I mean I have to say I’ve been in breast care nearly 7 years now and to start with the swimwear was quite – and the bras also were quite large and sort support, heavy support –

H: They looked a bit Victorian didn’t they?

V: Yes, yes – akin to maternity

H: Not pretty – you wouldn’t want to be seen on the beach in a skimpy one?

V: Well I know, and there wasn’t such a thing as a bikini, you know with a pocket where you could put a prosthesis – we’re obviously talking about women who’ve had mastectomies who haven’t had reconstructions, but no now you can get bikinis that have got little pockets in them, I mean there’s no end of –

H: Things are getting a lot better aren’t they?

V: Yes absolutely

H: To help regain confidence after having an operation and being scarred in some way

V: Plus the actual breast forms themselves, they’re much lighter now, I mean I run a weekly breast prosthesis clinic, much lighter, you can get ones that stick to the chest walls – scooped out ones –

H: So it’s not like wearing a bag of sugar in your bra any more?

V: No it used to be – it used to be water and then it used to be bird seed, rather alarmingly

H: Bird seed?

V: Yes, yes that’s what –

J: Really? Oh my God!

H: A little bit noisy!

V: Go to Trafalgar Square in those!

H: Ok we’ve got another anonymous question now, “should women who’ve had breast cancer avoid dairy products? I read that milk should be avoided but I’m worried about osteoporosis?”

V: I have to say I don’t think that there’s much medical evidence, not randomised controlled trials about dairy products. There’s a wealth of information on diet and breast cancer especially. I think it’s because maybe it’s, you know the control has been taken from you, you know you’ve had to have these treatments, and it’s something that people can do to gain some control, you know well I’m not going to have dairy products. I actually don’t think the evidence is very robust and I think if any of these make anyone feel better, like oh I’m not going to try – this is what I’m going to do –

J: Yes if it makes you feel good then do it

V: Great, and to be encouraged, but I don’t really think the medical evidence suggests that it’s so. I think some of these, ok so not with dairy, but some of them, like if you follow very strict fruit juice regiments, you know it can be quite restricting and expensive. Osteoporosis, quite right, you know I would say do weight-bearing exercises, don’t smoke, and –

H: Or if you’re worried get your calcium from other things like –

V: Yes exactly

H: Fruit and vegetables

V: Calcium, vitamin D supplement –

H: Have you got any tips, I mean if somebody is suffering from breast cancer, how – what should they be doing with their diet? Are there things that they should be including that perhaps they wouldn’t have included before? What would you say?

V: Well again it’s – there isn’t any robust evidence out there really, I think if anything makes anyone feel better then for them to follow that certainly, and some people like to go to homeopathists – homeopath even! And you know follows these different diet regimens but actually I think a well-balanced diet, with alcohol, I think certainly not to say no to anything, is actually – if you’re in crisis –

H: Did you follow a specific diet, did you –

J: No

H: Just eat very healthily?

J: I just ate as I was actually to be honest, yes I ate healthily, no I didn’t follow anything, nothing special, but I just think if that’s what you feel you want to do then do it, you know and it’s a mind thing as well

H: We’re getting a lot of questions about people concerned about the hereditary aspect of breast cancer. We’ve got one here, a lady just calls herself C, she hasn’t given a name – she says “my nan had breast cancer many years ago and had a mastectomy, went into remission and she was fine. I’m more than aware of the genetics involved and therefore assume that I’m in the line of fire, so to speak. I regularly do breast checks but have to say that irregular lumps and bumps appear and disappear all the time. Obviously key not to run to the doctors every 10 minutes. Is there a way of identifying bumps that begin, benign sorry, or when there’s something more sinister?”

V: I think the thing to absolutely remember is that the vast majority of breast cancer is just, there’s no reason for it. only about 4 or 5% of all breast cancers are hereditary, are through genes, it’s just common. One in nine women have it, absolutely –

H: So if your mother and your grandmother had it, doesn’t really mean necessarily –

V: I would say if they were in their 40s when they had it, which is very unlikely anyway, then there would be a chance, and then maybe we say you know you should go to a specialist centre 10 years previous to them, so if they were 40 on diagnosis of breast cancer, go when you’re 30 and have what we call a pedigree when they work out what your risk is, but I would say to C that if it was her grandmother then I would say that it’s just common, it’s just one of those things, and as I say 95% of breast cancer is random and to keep, yes breast aware, that’s great, know what’s normal for her

H: We’ve had a lot of questions on this hereditary thing, you hear stories – I mean I read recently about a woman who all the women in her family had had breast cancer and she chose to have a double mastectomy even though she didn’t have it –

J: Yes I remember

H: Aged 30 which is very young, but that’s not necessarily that if it’s in the family then, that that’s quite rare?

V: Well it is quite rare –

J: But it depends on the age of the person actually

V: It depends on the age and the number of people you know immediate relatives who’ve had it, and you can work there’s quite a sort of key way of working it out to see if you’re at risk, the vast majority of people aren’t but if there has been, you know quite a smattering if you like of people getting breast cancer at young ages, then I would say maybe go to your GP and get a you know non-urgent appointment, even for peace of mind

H: Better to be safe than sorry

V: Yes

H: Keira wants to know “my mum had breast cancer but I was too young to remember. Can you remind us what we should look out for?” Can you tell us Janice, what did you –

J: She was too – I found it by self-examination –

H: Self-examining

J: Self-examination. There was a lump there that wasn’t normal, because you are lumpy sometimes, specially your menstrual period time, but it was a lump that was never there before.

H: Is it difficult for some women to know what to look for, what should they be looking for?

V: I think it probably is, and again it’s the breast awareness rather than breast self-examination, it’s the notion of getting to know what’s normal for you, and perhaps sort of every month just after you have your monthly period, because then the breasts are less dense, you know know what’s normal, know if there’s any lumpiness, look in the mirror, raise your arms up, raise your arms down –

H: So that’s a good time of the month –

V: Absolutely

H: After your period, to examine –

V: Absolutely

H: Not before?

V: No before a whole hectic array of –

J: No you’re lumpy

V: Hormones going on, afterwards – easier

H: And how should you examine your breasts? I mean I was told you should use this part, the flat part of your hand, is that right?

V: Yes and some use, find it easier in the bath or the shower, you know and then looking into a mirror also and raising your hands up and seeing if there’s any dimpling or any sort of – you know gross –

H: Asymmetry

V: Asymmetry!

H: Doesn’t look quite right in other words!

J: Exactly!

V: Not even!

J: Any changes, yes

H: And to start? What age should women start, as soon as they develop their breasts at puberty?

V: Oh I think that’s slightly alarming to be honest –

H: Is that too young?

V: I mean we know that only 20% of breast cancers go in women who are under 50 so 80% of people who get breast cancer are 50 years and above really, so not to be so alarming, but just to keep being aware I guess, it should just be one of those body checks

H: Ok. Andrea wants to know “can the website also help my family and friends, can they get in touch with other families and carers of survivors? Strangely they feel less in control of things than I do and I’m the one who has the disease?” That’s quiet common isn’t it for the family to feel that?

J: Is there anyone for them to –

H: Other people for them to help the family and the friends not just the people who’ve got the disease, on this website?

J: There is a link to go for family and friends, yes, carers, no one to actually talk to but there is a link where you can get pamphlets etc and contact support groups

V: That’s a good idea actually because in the future if there is going to be a discussion zone in the website then –

J: Yes it would be a good idea

V: You could think, you know that could be sort of tail-doved in as well

J: Yes

H: Because did your – how did your family react, did they feel more out of control, like our questioner, that the family felt more out of control? Because Andrea said she was coping better herself than her family was?

J: No I don’t think my family did actually, I think they were quite – they were pretty good, I mean we’re quite a positive family really, all of us

H: You were very lucky really

J: I was very lucky yes, yes

H: Ok. Jenny wants to know “you’re very brave coming on here Janice, and telling us your story –

J: Thank you

H: She says “how comfortable do you feel telling the world about what happened to you?” You seem very comfortable

J: Yes I think maybe, all my life really I’m just positive and I just have to be positive about everything, and no I don’t feel too bad sitting here. I don’t know why really!

H: Do you feel it’s quite good that – to be able to help other people

J: To help other people, yes

H: And to tell your story to help people like Jenny and other people who want to know what it’s like?

J: Yes that’s why I think also this website, you can read our stories and yes it is helpful if you’ve been through something to help other people get through it

H: Do you find that Vickki that perhaps other sufferers can help sufferers –

V: Oh absolutely

H: Sometimes better than a health professional like yourself?

V: Absolutely in a totally different way, you know I think we’re very privileged with the work that we do, certainly at St Mary’s where I am, but it is this unique, if you’ve been through something you really have got empathy. I mean as I said I run a breast cancer support group where we meet monthly, and they are such close members, such strong members, and the vast majority of those actually are after five years, and I think also maybe it’s a place where, it’s a sort of sanctuary where maybe family and friends have thought right that’s enough now, you know that’s – we’ve got over that, you know life is busy, so maybe –

J: Get onto the next part

V: So it’s through meeting with other people that you realise that actually how can it not affect everything, an outlook and –

J: And you’re not isolated, there are a lot of you out there going through the same thing

H: That’s very important isn’t it, not to feel isolated?

J: Yes yes. I do feel like that, you must try and speak to people if you can

H: Well we’ve got a final question from Miriam, she wants to know “I know you said it earlier but can you remind us what we should do after the five year mark?”

V: I would suggest keep aware, keep aware, almost breast awareness but as I said with your new, say if you’ve got a scar, check the scar. Check the texture of it, the look of it. Know how you feel in yourself, know what your baseline is, know if you feel slightly off and if there’s ever any worry, go to your GP or contact your specialist centre. You should also, I think always go for your mammograms

J: Do keep your check-ups I think

V: Yes I think it can only help

H: And what about – would there be any personal advice from you, because you’ve been through it after the five year mark, what would you say to someone?

J: What I would say is really just be positive about life, don’t – I don’t take things for granted now, just carry on. Make your life, you know you’ve got to go forward, and just be as positive as you can be really and if you do need help or if you do want to speak to someone, I must say at the beginning I didn’t speak to anyone, I wasn’t the one to go and speak to people, that’s why I think this website is good because you can just look on it and you can go anywhere and get support if you need it

H: And just remind us Vickki, just before we go, remind everybody whose watching this what the website is called?

V: It’s called www.lifeafterfive.co.uk

H: Wonderful thank you very much girls for coming in and talking to us, thank you Janice for telling us your story because it is very personal, but I know, especially from the questions we’ve had that people will have enjoyed listening to you and be inspired by what you said, and thank you Vickki for such really good advice, and the link is at the bottom of the page, it is www.lifeafterfive.co.uk as Vickki said, or you can go to the bottom of the page, that’s it for the Healthcare show for now, we’ll see you next time, thank you very much for joining us and bye bye for now