SpaceOAR in Treatment of Prostate Cancer
Dr. Singh and Dr. Coplowitz discuss a treatment option for prostate cancer called SpaceOAR.
Featured Speakers:
Dr. Jaspreet Singh is a board certified urologist. He obtained his medical degree from the New York College of Osteopathic Medicine and completed his clinical internship at Brookdale University Hospital and Medical Center followed by general surgery and urologic surgical residencies at Albert Einstein Medical Center, and Hahnemann University Hospital. Dr. Singh has also completed clinical externships at Memorial Sloane Kettering Cancer Center and the Children Hospital of Philadelphia during his residency. Dr. Singh pursued additional fellowship training at Thomas Jefferson University Hospital in PA. His training includes experience and proficiency with minimally invasive robotic and laparoscopic procedures. He has a special interest in the diagnosis and treatment of ED (erectile dysfunction) prostate, bladder and kidney cancers, and urinary incontinence. Throughout residency and afterwards, Dr. Singh has sought to further advance his knowledge and surgical skill by continued training under the nation’s leading urologists and gynecologists.
Shana Coplowitz, MD | Jaspreet Singh, DO
Dr. Shana Coplowitz serves as the Medical Director of Radiation Oncology at St. Luke’s Cornwall Hospital’s (SLCH) Littman Cancer Center. Her clinical practice is focused on treating the full gamut of adult malignancies. Dr. Coplowitz completed her residency at New York Presbyterian Hospital- Weill Cornell Medical Center, where she served as chief resident. Dr. Coplowitz is Board Certified by the American Board of Radiology. She attended the University of South Florida College of Medicine, where she was elected to the Alpha Omega Alpha Honor Society. Dr. Coplowitz is extensively trained in 3-D conformal, IMRT, IGRT, SBRT, SRS and HDR brachytherapy. She is also committed to research and has presented her work at several national meetings, including the American Radium Society and American Society of Therapeutic Radiation Oncology (ASTRO) where she was awarded the Scientific Abstract Award in 2011. Through her affiliation with the Montefiore Health System, partnered with SLCH, she has worked to expand the Center’s scope of care. As medical director, she works with the Littman Cancer Center's comprehensive team comprised of physicians, nurses and technologists to ensure that patients receive cancer care close to home.Dr. Jaspreet Singh is a board certified urologist. He obtained his medical degree from the New York College of Osteopathic Medicine and completed his clinical internship at Brookdale University Hospital and Medical Center followed by general surgery and urologic surgical residencies at Albert Einstein Medical Center, and Hahnemann University Hospital. Dr. Singh has also completed clinical externships at Memorial Sloane Kettering Cancer Center and the Children Hospital of Philadelphia during his residency. Dr. Singh pursued additional fellowship training at Thomas Jefferson University Hospital in PA. His training includes experience and proficiency with minimally invasive robotic and laparoscopic procedures. He has a special interest in the diagnosis and treatment of ED (erectile dysfunction) prostate, bladder and kidney cancers, and urinary incontinence. Throughout residency and afterwards, Dr. Singh has sought to further advance his knowledge and surgical skill by continued training under the nation’s leading urologists and gynecologists.
Transcription:
SpaceOAR in Treatment of Prostate Cancer
Melanie Cole (Host): SpaceOAR Hydrogel is an option for men who undergo radiation treatment for prostate cancer. Today we’re talking about this amazing technology and my guests in the panel discussion today are Dr. Jaspreet Singh. He’s a board certified urologist and Co-Medical Director of the Montefiore St. Luke's Cornwall Urology Services and Dr. Shana Coplowitz. She’s a board certified radiation oncologist and the Medical Director of Cornwall Radiation Oncology Services. Doctors, I’m so glad to have you with us today. What a fascinating bit of technology this is. Dr. Coplowitz, I’d like to start with you. What used to be the major side effect for men undergoing radiation for prostate cancer? What did you use to concern yourself with that maybe has changed a little bit now?
Dr. Shana Coplowitz (Guest): The truth of the matter is that radiation to the prostate is probably one of the easier radiations that we do. The side effects are actually fairly minimal, but the two main areas – or really three main areas that we worry about are urinary function, GI function, and sexual function. So during radiation, patients will sometimes experience increased frequency of urination, waking up more often at night to go to the bathroom. The GI side effects typically don’t happy during the treatment, although occasionally patients can experience looser bowels, but that’s usually more of a later side effect and we worry about something called radiation proctitis which is rectal bleeding related to the radiation and then erectile dysfunction can sometimes happen in the long term.
Host: So Dr. Singh, what is SpaceOAR Hydrogel that I mentioned in my intro? What does it stand for and why the need? What’s the evolution of it?
Dr. Jaspreet Singh (Guest): You know the goal of radiation therapy is to maximize radiation to the prostate, as Dr. Coplowitz was saying, as she’s treating the prostate for prostate cancer, but unfortunately, the way that radiation is delivered, it has – some of the radiation can effect the surrounding tissue and the prostate sits in a very delicate spot. It’s surrounding the urinary channel, called the urethra, it sits next to the bladder, and in front of the rectum. So to avoid radiating the surrounding normal tissue, you need to help space or create a space in between the rectum and the prostate and this is where this technology comes into play. You see the rectum and the prostate are very close and are only naturally separated by a small space, and due to this closeness, the prostate radiation therapy can potentially cause damage to the rectum. So what SpaceOAR does, Space O-A-R, the technology is Hydrogel, a gel like material that is very commonly seen in capsules that we eat, the Advil capsules or – you know the gel like material, and what that does is that’s injected in front of the rectum and it temporarily moves the prostate away from the rectum, allowing radiation oncologists, like Dr. Coplowitz to then deliver the radiation and feel more confident in not allowing some of that radiation to effect the rectum.
Host: It’s pretty cool, isn’t it? So Dr. Coplowitz, tell us about the space or procedure, what’s that like, and which one of you would do this procedure? Is it the radiation oncologist or does the urologist set it up and then you take it from there? Tell us how this works.
Dr. Coplowitz: So Dr. Singh actually is the one who would do the actual procedure, but typically any patient who we think is appropriate for the procedure, I would be seeing them, I would be talking to them about it and then I would have them go and see Dr. Singh to actually have the procedure done.
Dr. Singh: Melanie if I may add, this is one of the advantages in being in the community and working close with a radiation oncologist that you trust. The communication is impeccable and so when I see a patient, often diagnose the patient with prostate cancer in my office, who is thinking about radiation therapy, I actually have the option to pick up the phone right there and let Dr. Coplowitz know that so and so is coming in and a lot of that information is sitting at her desk when the patient comes for a consultation. We discuss these things and this is why it’s important to have a team approach to treating prostate cancer, and so we kind of have an idea of how we’re going to approach a patient, present the options that are there. No everyone chooses the SpaceOAR. I would say most patients do because the advantages are there and the potential downsides or risks are very minimal. Now as far as the procedure goes, it’s an outpatient procedure which we commonly do in the office, and it’s a procedure that most patients will choose slight anesthesia, almost like a colonoscopy type sedation and 7 to 10 minutes of that sedation allows the patient to be comfortable. What the procedure itself is, is an ultrasound that’s placed into the rectum and we use that ultrasound to map out the prostate. We identify the space that’s in between the rectum and the prostate and really the gel part of it, the injection part of it takes less than 2 minutes to instill it in the right location. So it’s not a very complex procedure but has significant quality of life improvements or potential quality of life improvements with this intervention.
Host: Wow, that’s absolutely fascinating. Dr. Coplowitz, tell us really – Dr. Singh has explained the procedure and he explained basically what it does, but how does it do what it does? What does it mean when you say it’s pushing the organs out of the way or protecting them? Tell us a little bit about how it works and how long does it last?
Dr. Coplowitz: So the way that the radiation works is we deliver the high dose of radiation to the prostate, but radiation’s not magic. There is some area of radiation that kind of falls off the further you get away from the prostate, but when the rectum is sitting directly abutting the prostate, it’s going – the anterior part of the rectum will receive some amounts of radiation. So what the gel does is it actually artificially creates a space, and it’s actually physically pushing the rectum away from the prostate, and because of that, it’s moving out of that dose fall off area, and it’s really moving out of the way and we’re able to curve our radiation doses. We use a technique called IMRT, intensity modulated radiation therapy, and with that technique we’re able to kind of curve out the rectum from our treatment area and really the rectum will get very minimal doses of radiation, almost nothing, which is really kind of unheard of without this SpaceOAR so it’s really a very, very neat technique to use.
Host: What happens to the gel Dr. Coplowitz? If radiation treatments are an 8 week long program, then does it last that long? Does it need to be re-done and what happens to it?
Dr. Coplowitz: Right, so we actually have to time this very well because the gel does not last forever. It typically will disintegrate within a few months, and so what happens is we try to coordinate and make sure that we’re having this gel put in typically right before we’re ready to start the radiation because some patients will be getting hormone therapy before they start the radiation and so it will delay the start of radiation treatment by about two months while the hormones are kind of starting to work, and starting to kick in, and if we put that gel in right at the beginning, it would be almost gone before they finish the radiation treatment, so we really have to try to coordinate and make sure that they’re getting the gel put in right before they start the treatment.
Host: Dr. Singh, what would you like listeners to know about this? Is it ever contraindicated? Are there some people that you really would say this is really not an option for this person? But what would you like them to know about this amazing bit of technology?
Dr. Singh: The SpaceOAR is actually a very safe procedure. Potential complications obviously can be from misplacement of the gel, but that is unusual and that’s why it’s important to go to a urologist that’s comfortable in doing this procedure. We’ve heard stories about the gel being put in the bladder or the rectum. Now it’s not harmful. It’s a biodegradable material, and as Dr. Coplowitz was mentioning, it takes about three months for this gel matrix to dissolve, and once the body absorbs it, roughly 3 to 4 months after instillation, most patients just urinate it out. So that’s how it’s excreted out of the body, gets absorbed and out, so it’s not harmful in that sense. As far as what to expect after the procedure, most patients will report some rectal pressure which usually lasts about 24 hours and that’s understandable as there’s an ultrasound probe placed in the rectum during the procedure. Physically there aren’t any limitations and the patient does necessarily have any restrictions after the procedure and as far as the timing that Dr. Coplowitz was saying is that’s something we coordinate all the time to make sure and ensure that there is enough time that, that matrix is going to be there for Dr. Coplowitz to deliver the radiation. Besides the toxicity prevention that SpaceOAR has provided that we had discussed in limiting irritation to the bowels, the urinary bladder, as well as the sexual side effects, I think it has also provided Dr. Coplowitz to allow treating the prostate with radiation therapy and dose modifying it and allowing, or to perhaps treat it in a different way, and I would like Dr. Coplowitz to kind of discuss that. I think that’s a very important advantage that this technology has also offered our patients.
Dr. Coplowitz: So thank you for segueing into that. I just wanted to mention one thing first. You had asked about any contraindications. The one thing to keep in mind is when we do a radiation planning, we have patients come for a CAT scan and that’s how we plan the radiation, but the gel actually won’t show up on a CAT scan so patients need to go for an MRI because we’re able to see the gel on the MRI sequences and then we fuse that with our CAT scan to do radiation planning. So any patients who are unable to have an MRI for whatever reason, those are patients that we would not be able to have do the gel because we would not be able to do the planning, we basically would lose the benefit of having the spacer in place, but to Dr. Singh’s point about changing the radiation dosing – so this is one reason that the spacer is so exciting. So typically the way that we used to deliver radiation treatments to the prostate was every day, Monday through Friday, for 45 treatments, so 9 weeks of treatment which is really quite a time commitment for people to come, but with the SpaceOAR, I’m feeling much more comfortable in doing something called hypofractionation, which means treating patients in a shorter number of treatments. So now we’re offering treatments in 28 treatments, which is 5 and half weeks of treatment, which is a significant time difference, and the reason that the SpaceOAR allows us to do that is when we treat with these shorter treatments, it’s actually a higher dose of radiation with each treatment, so the concern is with that higher dose, you might be giving a higher dose to the rectum, and as I mentioned, the rectum can be very sensitive to radiation, and so we want to be as safe as possible when we deliver the radiation, and putting that SpaceOAR in gives us that comfort level. We know that we’re not going to be giving the rectum too much radiation and this way we’re able to shorten the treatments with essentially no increase in side effects, and maybe even less side effects.
Host: Wow, what a benefit for the men and you explained that so very well. Dr. Coplowitz, I’d like to give you the first last word here. What would you like the listeners to take away from this incredible segment about this technology that you use along with Dr. Singh and this comprehensive approach to treating prostate cancer?
Dr. Coplowitz: So what I’d like people to take away is that at Montefiore St. Luke's, we are always trying to bring patients the most up to date technology to do everything in the safest, most effective way possible, and to make things as convenient and easy as possible.
Host: Dr. Singh, off to you, what would you like the listeners to know about working together, treating men with prostate cancer, and the SpaceOAR hydrogel?
Dr. Singh: You know prostate cancer, or for that matter, any news on cancer is a life changing event. What we have here at Montefiore St. Luke's Hospital is a team that is providing top notch care, whether it comes to coordinating the care, the pretreatment algorithm, during the treatment, and then even care afterwards as we have a very comprehensive network for nursing navigators to help patients out. What this technology is offering, the SpaceOAR, is allowing my patients to undergo radiation treatment for prostate cancer in a safe procedure that’s allowing fewer rectal complications, fewer urinary side effects, and also preserving a good quality of life and maintaining sexual function as well. So I know nobody wants to hear that they have cancer, but truly we are providing treatment for prostate cancer, and always considering minimizing side effects and maintaining quality of life for our patients.
Host: What great info, thank you both so much. Really, what a very cool segment, and that wraps up this episode of Doc Talk presented by Montefiore St. Luke's Cornwall. Head on over to our website at montefioreslc.org for more information and to get connected with one of our providers. If you found this podcast as cool as I did, and so informative, please share with your friends and family, share with men that you know that have prostate cancer, and with the people that love them, share on your social media – this is the exciting technology that’s happening today and you’re learning about it from the experts at Montefiore St. Luke's Cornwall and be sure to check out all the other interesting podcasts in our library. Until next time, I’m Melanie Cole.
SpaceOAR in Treatment of Prostate Cancer
Melanie Cole (Host): SpaceOAR Hydrogel is an option for men who undergo radiation treatment for prostate cancer. Today we’re talking about this amazing technology and my guests in the panel discussion today are Dr. Jaspreet Singh. He’s a board certified urologist and Co-Medical Director of the Montefiore St. Luke's Cornwall Urology Services and Dr. Shana Coplowitz. She’s a board certified radiation oncologist and the Medical Director of Cornwall Radiation Oncology Services. Doctors, I’m so glad to have you with us today. What a fascinating bit of technology this is. Dr. Coplowitz, I’d like to start with you. What used to be the major side effect for men undergoing radiation for prostate cancer? What did you use to concern yourself with that maybe has changed a little bit now?
Dr. Shana Coplowitz (Guest): The truth of the matter is that radiation to the prostate is probably one of the easier radiations that we do. The side effects are actually fairly minimal, but the two main areas – or really three main areas that we worry about are urinary function, GI function, and sexual function. So during radiation, patients will sometimes experience increased frequency of urination, waking up more often at night to go to the bathroom. The GI side effects typically don’t happy during the treatment, although occasionally patients can experience looser bowels, but that’s usually more of a later side effect and we worry about something called radiation proctitis which is rectal bleeding related to the radiation and then erectile dysfunction can sometimes happen in the long term.
Host: So Dr. Singh, what is SpaceOAR Hydrogel that I mentioned in my intro? What does it stand for and why the need? What’s the evolution of it?
Dr. Jaspreet Singh (Guest): You know the goal of radiation therapy is to maximize radiation to the prostate, as Dr. Coplowitz was saying, as she’s treating the prostate for prostate cancer, but unfortunately, the way that radiation is delivered, it has – some of the radiation can effect the surrounding tissue and the prostate sits in a very delicate spot. It’s surrounding the urinary channel, called the urethra, it sits next to the bladder, and in front of the rectum. So to avoid radiating the surrounding normal tissue, you need to help space or create a space in between the rectum and the prostate and this is where this technology comes into play. You see the rectum and the prostate are very close and are only naturally separated by a small space, and due to this closeness, the prostate radiation therapy can potentially cause damage to the rectum. So what SpaceOAR does, Space O-A-R, the technology is Hydrogel, a gel like material that is very commonly seen in capsules that we eat, the Advil capsules or – you know the gel like material, and what that does is that’s injected in front of the rectum and it temporarily moves the prostate away from the rectum, allowing radiation oncologists, like Dr. Coplowitz to then deliver the radiation and feel more confident in not allowing some of that radiation to effect the rectum.
Host: It’s pretty cool, isn’t it? So Dr. Coplowitz, tell us about the space or procedure, what’s that like, and which one of you would do this procedure? Is it the radiation oncologist or does the urologist set it up and then you take it from there? Tell us how this works.
Dr. Coplowitz: So Dr. Singh actually is the one who would do the actual procedure, but typically any patient who we think is appropriate for the procedure, I would be seeing them, I would be talking to them about it and then I would have them go and see Dr. Singh to actually have the procedure done.
Dr. Singh: Melanie if I may add, this is one of the advantages in being in the community and working close with a radiation oncologist that you trust. The communication is impeccable and so when I see a patient, often diagnose the patient with prostate cancer in my office, who is thinking about radiation therapy, I actually have the option to pick up the phone right there and let Dr. Coplowitz know that so and so is coming in and a lot of that information is sitting at her desk when the patient comes for a consultation. We discuss these things and this is why it’s important to have a team approach to treating prostate cancer, and so we kind of have an idea of how we’re going to approach a patient, present the options that are there. No everyone chooses the SpaceOAR. I would say most patients do because the advantages are there and the potential downsides or risks are very minimal. Now as far as the procedure goes, it’s an outpatient procedure which we commonly do in the office, and it’s a procedure that most patients will choose slight anesthesia, almost like a colonoscopy type sedation and 7 to 10 minutes of that sedation allows the patient to be comfortable. What the procedure itself is, is an ultrasound that’s placed into the rectum and we use that ultrasound to map out the prostate. We identify the space that’s in between the rectum and the prostate and really the gel part of it, the injection part of it takes less than 2 minutes to instill it in the right location. So it’s not a very complex procedure but has significant quality of life improvements or potential quality of life improvements with this intervention.
Host: Wow, that’s absolutely fascinating. Dr. Coplowitz, tell us really – Dr. Singh has explained the procedure and he explained basically what it does, but how does it do what it does? What does it mean when you say it’s pushing the organs out of the way or protecting them? Tell us a little bit about how it works and how long does it last?
Dr. Coplowitz: So the way that the radiation works is we deliver the high dose of radiation to the prostate, but radiation’s not magic. There is some area of radiation that kind of falls off the further you get away from the prostate, but when the rectum is sitting directly abutting the prostate, it’s going – the anterior part of the rectum will receive some amounts of radiation. So what the gel does is it actually artificially creates a space, and it’s actually physically pushing the rectum away from the prostate, and because of that, it’s moving out of that dose fall off area, and it’s really moving out of the way and we’re able to curve our radiation doses. We use a technique called IMRT, intensity modulated radiation therapy, and with that technique we’re able to kind of curve out the rectum from our treatment area and really the rectum will get very minimal doses of radiation, almost nothing, which is really kind of unheard of without this SpaceOAR so it’s really a very, very neat technique to use.
Host: What happens to the gel Dr. Coplowitz? If radiation treatments are an 8 week long program, then does it last that long? Does it need to be re-done and what happens to it?
Dr. Coplowitz: Right, so we actually have to time this very well because the gel does not last forever. It typically will disintegrate within a few months, and so what happens is we try to coordinate and make sure that we’re having this gel put in typically right before we’re ready to start the radiation because some patients will be getting hormone therapy before they start the radiation and so it will delay the start of radiation treatment by about two months while the hormones are kind of starting to work, and starting to kick in, and if we put that gel in right at the beginning, it would be almost gone before they finish the radiation treatment, so we really have to try to coordinate and make sure that they’re getting the gel put in right before they start the treatment.
Host: Dr. Singh, what would you like listeners to know about this? Is it ever contraindicated? Are there some people that you really would say this is really not an option for this person? But what would you like them to know about this amazing bit of technology?
Dr. Singh: The SpaceOAR is actually a very safe procedure. Potential complications obviously can be from misplacement of the gel, but that is unusual and that’s why it’s important to go to a urologist that’s comfortable in doing this procedure. We’ve heard stories about the gel being put in the bladder or the rectum. Now it’s not harmful. It’s a biodegradable material, and as Dr. Coplowitz was mentioning, it takes about three months for this gel matrix to dissolve, and once the body absorbs it, roughly 3 to 4 months after instillation, most patients just urinate it out. So that’s how it’s excreted out of the body, gets absorbed and out, so it’s not harmful in that sense. As far as what to expect after the procedure, most patients will report some rectal pressure which usually lasts about 24 hours and that’s understandable as there’s an ultrasound probe placed in the rectum during the procedure. Physically there aren’t any limitations and the patient does necessarily have any restrictions after the procedure and as far as the timing that Dr. Coplowitz was saying is that’s something we coordinate all the time to make sure and ensure that there is enough time that, that matrix is going to be there for Dr. Coplowitz to deliver the radiation. Besides the toxicity prevention that SpaceOAR has provided that we had discussed in limiting irritation to the bowels, the urinary bladder, as well as the sexual side effects, I think it has also provided Dr. Coplowitz to allow treating the prostate with radiation therapy and dose modifying it and allowing, or to perhaps treat it in a different way, and I would like Dr. Coplowitz to kind of discuss that. I think that’s a very important advantage that this technology has also offered our patients.
Dr. Coplowitz: So thank you for segueing into that. I just wanted to mention one thing first. You had asked about any contraindications. The one thing to keep in mind is when we do a radiation planning, we have patients come for a CAT scan and that’s how we plan the radiation, but the gel actually won’t show up on a CAT scan so patients need to go for an MRI because we’re able to see the gel on the MRI sequences and then we fuse that with our CAT scan to do radiation planning. So any patients who are unable to have an MRI for whatever reason, those are patients that we would not be able to have do the gel because we would not be able to do the planning, we basically would lose the benefit of having the spacer in place, but to Dr. Singh’s point about changing the radiation dosing – so this is one reason that the spacer is so exciting. So typically the way that we used to deliver radiation treatments to the prostate was every day, Monday through Friday, for 45 treatments, so 9 weeks of treatment which is really quite a time commitment for people to come, but with the SpaceOAR, I’m feeling much more comfortable in doing something called hypofractionation, which means treating patients in a shorter number of treatments. So now we’re offering treatments in 28 treatments, which is 5 and half weeks of treatment, which is a significant time difference, and the reason that the SpaceOAR allows us to do that is when we treat with these shorter treatments, it’s actually a higher dose of radiation with each treatment, so the concern is with that higher dose, you might be giving a higher dose to the rectum, and as I mentioned, the rectum can be very sensitive to radiation, and so we want to be as safe as possible when we deliver the radiation, and putting that SpaceOAR in gives us that comfort level. We know that we’re not going to be giving the rectum too much radiation and this way we’re able to shorten the treatments with essentially no increase in side effects, and maybe even less side effects.
Host: Wow, what a benefit for the men and you explained that so very well. Dr. Coplowitz, I’d like to give you the first last word here. What would you like the listeners to take away from this incredible segment about this technology that you use along with Dr. Singh and this comprehensive approach to treating prostate cancer?
Dr. Coplowitz: So what I’d like people to take away is that at Montefiore St. Luke's, we are always trying to bring patients the most up to date technology to do everything in the safest, most effective way possible, and to make things as convenient and easy as possible.
Host: Dr. Singh, off to you, what would you like the listeners to know about working together, treating men with prostate cancer, and the SpaceOAR hydrogel?
Dr. Singh: You know prostate cancer, or for that matter, any news on cancer is a life changing event. What we have here at Montefiore St. Luke's Hospital is a team that is providing top notch care, whether it comes to coordinating the care, the pretreatment algorithm, during the treatment, and then even care afterwards as we have a very comprehensive network for nursing navigators to help patients out. What this technology is offering, the SpaceOAR, is allowing my patients to undergo radiation treatment for prostate cancer in a safe procedure that’s allowing fewer rectal complications, fewer urinary side effects, and also preserving a good quality of life and maintaining sexual function as well. So I know nobody wants to hear that they have cancer, but truly we are providing treatment for prostate cancer, and always considering minimizing side effects and maintaining quality of life for our patients.
Host: What great info, thank you both so much. Really, what a very cool segment, and that wraps up this episode of Doc Talk presented by Montefiore St. Luke's Cornwall. Head on over to our website at montefioreslc.org for more information and to get connected with one of our providers. If you found this podcast as cool as I did, and so informative, please share with your friends and family, share with men that you know that have prostate cancer, and with the people that love them, share on your social media – this is the exciting technology that’s happening today and you’re learning about it from the experts at Montefiore St. Luke's Cornwall and be sure to check out all the other interesting podcasts in our library. Until next time, I’m Melanie Cole.