Professor Biscuit has been having some blood in his urine, and Dr. Roark is seeing something that doesn’t look right in the poor guy’s bladder. Today we talk with Veterinary Oncologist Dr. Sandra Bechtel about Transitional Cell Carcinoma and how we can best approach it. Let’s get into it!
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ABOUT OUR GUEST
Sandra (Axiak) Bechtel is a Veterinary Medical Oncologist and Associate Professor at the University of Florida in Gainesville, FL. She graduated from Michigan State University’s College of Veterinary Medicine in 2004 followed by an internship at Mississippi State University and Medical Oncology residency at Gulf Coast Veterinary Specialists. She achieved board certification in Medical Oncology in 2008 and practiced as an Associate Oncologist at Veterinary Specialists of North Texas in Dallas and Assistant/Associate Professor at the University of Missouri prior to joining the University of Florida in 2017. She loves teaching veterinary students how to apply their didactic education to patient care and to understand the goals of cancer therapy in dogs and cats. Her research focuses on improving the lives of companion animals with naturally occurring cancer and providing translational models for research in cancer causation, progression, and treatment. Particular areas of interest include novel diagnostics and treatments in cancer therapy and immune system dysfunction and modulation in cancer. This focus provides advanced cancer treatment for companion animals and essential information for translation of novel treatments into people. She has lectured and published extensively on her research in translational oncology. She relishes outdoor activities with her husband Scott and daughter Ainsley, and enjoys taking her boisterous Cavalier King Charles Spaniel, Watson for long walks.
EPISODE TRANSCRIPT
This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.
Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a great one today. I am here with my friend veterinary medical oncologist and associate professor at the University of Florida College of Vet Medicine, Dr. Sandra Bechtel. We are talking about a poor little dog straining to pee, and we get into transitional cell carcinoma and what you need to know, guys, this episode is brought to you ad free by my friends at cruise. Learn more at cruise.com. Now let’s get into this episode.
Kelsey Beth Carpenter:
(Singing) This is your show, we’re glad you’re here, we want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.
Dr. Andy Roark:
Welcome to the podcast Dr. Sandra Bechtel. Thanks for being here.
Dr. Sandra Bechtel:
Thanks for having me. I’m excited.
Dr. Andy Roark:
Oh, it’s my, all my pleasure. I love getting to work with you. Thanks for doing this. I appreciate you taking time out of your day as a veterinary medical oncologist at the university of Florida to take my question, because I got a case for you. You ready?
Dr. Sandra Bechtel:
I’m ready.
Dr. Andy Roark:
Sweet. I have a seven year old male castrated West Highland Terrier named Professor Biscuit and Professor Biscuit is…he’s got blood in his urine and the presenting complaint about this was…mom and dad come in and they, he had never had any problems like this before. He was not a urinary track guy. You know, any of that sort of stuff had some allergy stuff early on in his life that they got pretty well managed, but he started having blood in his urine. So he went to another veterinarian and they empirically treated with some antibiotics. So they were like, it’s probably a urinary tract infection. I wasn’t there. I don’t know. I don’t know why they jumped straight to empiric treatment or if they did diagnostics that I’m not getting access to. I don’t know. But the take home from mom and dad is that Professor Biscuit was having some blood in his pee and he got antibiotics and it got better.
Dr. Andy Roark:
And now he’s off antibiotics and its come right back and they’re like, can I have some more antibiotics? And I’m like, I don’t think so. I have concerns. And so I am worried about this. And as I think about getting a ultrasound guided cysto, I’m seeing some things in this bladder that I don’t like that would make me reach out to my friend, who’s an oncologist. And so I am worried about transitional cell carcinoma in this case. I want to make sure I get it right. I don’t want to, I don’t want to make it worse. And I also want to set realistic expectations. Can you just real quick, can you run me through, how do you treat that?
Dr. Sandra Bechtel:
Absolutely. I think that’s really reasonable when you have a dog and sometimes you may end up treating what could be a urinary tract empirically because clients might decline and-
Dr. Andy Roark:
Sure. Of course, Yeah [crosstalk 03:11:00]
Dr. Andy Roark:
I won’t throw anybody under the bus like 100% [crosstalk 03:13:00].
Dr. Sandra Bechtel:
Sure. And you treat it that first time and then it comes back and you’re correct, that’s just not right. And so to keep throwing antibiotics at the situation is just a little bit, it doesn’t feel quite right. And you’re worried, is this the same infection that came back? Was it just not treated long enough? Is it so is it refractory or recurrent? I mean, or is it refractory? Do we have a different bug in there? Is it a different infection, it a resistant infection or is there something underlying that is actually causing us to be more susceptible to a urinary tract infection? So when you take a look at that bladder and you see something in there and you think, huh, I don’t like the way this looks, that’s a really good place to go. Those things that you’re going to be looking for would be things like bladder mass. Of course, we’re always worried about transitional cell carcinoma being the most common or there may be even bladder stones.
Dr. Sandra Bechtel:
Those are something to look for as well. And when we, I don’t often as an oncologist get dogs that early in the initial workup, but when I do, I do let them know that we’re not always looking for cancer and that there are other things on our differential list that we need to make sure are or aren’t there before we start talking and jumping into treatment.
Dr. Sandra Bechtel:
But if you know, you do your bladder ultrasound and you see what looks like it might be a mass and that’s something where before you do that cysto, which is, I know exactly where you’re going with that you might want to take a step back and think, huh, there could be a bladder mass there, maybe a cysto isn’t our next best step, at least at this point in time. And that’s because with transitional cell carcinomas, we know that there’s that risk of seeding of tumor cells through the bladder wall and the published risk of that seeding through cystocentesis is fairly low.
Dr. Sandra Bechtel:
It’s less than 10%. It’s closer to 4% in the published literature. And, but if it happens, it’s pretty bad for that dog. So at least for us is, if it’s something we can avoid, we will try our very best to avoid that. hen we know we have that infection that is occurring, the clinical signs of that potential infection are occurring again after antibiotics, we want to get the urinalysis and urine culture. Is there a safer way for us to go ahead and collect urine and get good culture results? And in particular with male dogs, it’s at least quite a bit easier. I think anyway,there’s lots of people who are very skilled at catheterizing female dogs, but urinary catheters in male dogs are quite easy to place. So this is a situation in which urinary catheter can be placed sterilely and help us collect that sterile sample for both urinalysis and urine culture and also be quite safe.
Dr. Andy Roark:
OK. What are you looking for in a…and this sounds like maybe a bit of odd question, but what are you looking for in a catheter? Like how does, I mean, is it this classic red rubbers? Are there, is there, I don’t know any just general guidelines for what I’m picking out, that’s going to get me the best sample, that’s maybe not going to be traumatic or anything like that.
Dr. Sandra Bechtel:
Sure. So in addition to the general length and size of the catheter itself, and we want it to be stiff enough so that we can place it easily, but not so stiff that it’s going to be uncomfortable. And if I’m just collecting just a quick urine sample for urinalysis or culture in a dog with a suspected bladder tumor, and that’s super worried about using something like a balloon or Foley catheter that I need to stay in place.
Dr. Andy Roark:
Gotcha.
Dr. Sandra Bechtel:
Now I will be using those if I have a confirmed bladder tumor dog and I’m using ultrasound to subsequently look at bladder mass size, we often will place a catheter with each ultrasound during the bladder and then put in the same amount of saline each time we do the ultrasound, just so that the bladder itself is the same size. So that way, ideally we’re getting the, at least as close as we can in the same measure with each abdominal ultrasound, but on the initial collection, it’s usually just a quick, you know, what’s the quickest, easiest and most comfortable for the pet.
Dr. Andy Roark:
That’s what I needed.
Dr. Sandra Bechtel:
And so I think that’s a great place to start. And sometimes if there is not a lot of inflammation in the bladder, you can sometimes even get some cells on the urinalysis and on the urine sediment that might help clue you in as to whether or not you might be dealing with the cancer. If there is a lot of inflammation, so if you have a secondary urinary tract infection, what you might see on that urine sediment, those cells may look pretty scary, but inflammation can actually make the cells look cancerous and they may just be reactive. So, you may not be able to get that definitive answer if there’s a lot of inflammation in the background.
Dr. Andy Roark:
Okay. So, beyond catheterization, urinalysis, cytology, things like that. What…are there other diagnostics that I want to get pretty early on? I mean, chest radiographs, things like that, looking for spread, what’s the likelihood that those are going to be valuable?
Dr. Sandra Bechtel:
So early on in the diagnostic process, and it depends on how my clients feel, there’s a lot that we can do, but I like to see where my clients are both emotionally and financially in the process. So if I have more of a thickened and inflamed bladder wall, but not really a distinctive mass yet, I may focus more on trying to get the cystitis under control before getting to too heavy on the staging tools, unless I have a confirmed cancer present. If I have clients who are like, yes, let’s do everything. Then I would love to do full staging. That would be three-view chest x-rays and a full abdominal ultrasound to look for any evidence of cancer movement. Transitional cell carcinoma being the most common of the bladder tumors does like to go through lymph nodes, liver, spleen lungs, and sometimes even to bone later in the stage of disease.
Dr. Sandra Bechtel:
Yeah. But initially before I have a diagnosis, we could do things like, look at that urine sediment to look at…and if, again as long as there’s not a whole lot of inflammation, sometimes we can get an answer there. We can do the BRAF test and that’s a urine test. Does have to be done on free catch urine. Can’t actually be done on cystocentesis or urinary catheter collected samples, just because it tends not to get as many cells as a free catch. And you, need a lot of urine for it, so Professor Biscuit, who is a Westie, you need probably 30 to 40 milliliters of urine. So we actually send it home with the owners to collect in one container and put into the collection cup. Because it has a preservative in it. So owners get to chase around their dogs with the collection cup in the yard.
Dr. Andy Roark:
Talk to me a little bit more about the BRAF test. So, it’s not one that I’ve used.
Dr. Sandra Bechtel:
So it is not invasive, which is what makes it really quite nice, and the publications out there show that it’s both sensitive and specific. And it’s actually looking for, in the cells of the lining of the bladder that are shed into the urine, it’s looking for a specific genetic mutation that is found in transitional cell carcinomas. When those…that mutation is actually found it, in almost all cases, can confirm the presence of transitional cell carcinomas. We’re pretty confident when there’s a bladder mass and the presence of the BRAF mutation, we’re pretty confident in a diagnosis of transitional cell carcinoma. If there is a bladder mass and there is not the BRAF mutation, then we need to do other diagnostics to see what is there, because we can get some false negatives.
Dr. Andy Roark:
Okay. So, other diagnostics just being cytology, biopsy, in some cases, things like that.
Dr. Sandra Bechtel:
Yes. So we may need to do things like a diagnostic catheterization, or we may need to do cystoscopy with biopsies or other things to get a better idea of what’s going on in the bladder.
Dr. Andy Roark:
When, unfortunately, this comes back as transitional cell carcinoma, so say we get a positive result and we can confirm the diagnosis. How do you approach this conversation with the pet owners? Like what just going in, aside from some breaking the news, what expectations do you try to set just as you open this conversation and try to get them to see what a post diagnosis life is going to be like?
Dr. Sandra Bechtel:
So, it is a hard conversation to have because it’s not a cancer that we can cure. And I think that is probably one of the most important expectations to set up from the beginning. And we tend to, and I think this is probably an oncologist view, but we tend to think of cancer as more of a chronic disease process. And I think cancer is a very scary word. So when you hear heart disease or kidney disease, it’s maybe not as scary to hear as cancer. So, we try to think of it more as a chronic disease management. And we just have different tools to manage cancer than we would for kidney disease or heart disease. And in a similar way, transitional cell carcinoma is a disease that we try to manage with a real focus on quality of life. Because certainly if your bladder is inflamed and very thick, it seems like it would be very uncomfortable for pets.
Dr. Sandra Bechtel:
And so that first focus is what can we do to make our pets more comfortable and what options do we have to provide that comfort for as long as we can. So one of the things that we need to focus on is, is there a secondary urinary tract infection? And if there is what is the correct antibiotic to who have this pet on and for how long? And so with these bladder tumors, by definition, they’re complicated infections. So we’re looking at culture based treatment for four to six weeks and checking that culture seven to 10 days after starting antibiotics and about a week after completing antibiotics to try and avoid an antibiotic resistant infection. Which can be life limiting.
Dr. Andy Roark:
OK. Yeah. No, that makes sense.
Dr. Sandra Bechtel:
Yeah. So those can be life limiting in some patients that have been on multiple empirical short courses of antibiotics. The second thing we want to focus on is, if safe, we want to use a nonsteroidal anti-inflammatory. Ideally Piroxicam, that’s been shown to be very effective in a lot of cases, not in just decreasing inflammation and providing comfort, but in some cases can even shrink down the size of the tumor itself. So that by itself can be an effective treatment for transitional cell carcinomas and it’s pretty affordable too.
Dr. Andy Roark:
What’s the difference between, whenever you and I have talked about this in the past, and there’s always been people around who have asked, what about this other non-steroidal? How much is the difference between [Inaudible 13:19:00] Piroxicam is the gold standard so I’ve heard, how is it, I guess what I’m saying is when my colleague says, “Oh, can we use Carprofen. Can we use something else?” What is the difference between the two? Is it…I don’t know. I guess what I’m saying, is it worth saying this is the one or are there instances where we’ll choose alternatives?
Dr. Sandra Bechtel:
That is a great question and I don’t know the answer to it because we have not had any studies comparing the different nonsteroidals side by side. We do tend to try and stick with the ones that have been looked at and shown to be effective in transitional cell carcinomas. Piroxicam has been used the most often and I think we really like that one, because we’ve seen that work so often, but there are times where it does tend to be the least well tolerated. So if we can’t tolerate Piroxicam, Firocoxib and Deracoxib have also been studied as a single agent for transitional cell carcinoma. Then for other nonsteroidals the answer is we just don’t know because they haven’t been looked at, but certainly if that’s what is tolerated then, and if it seems to be working for that particular patient, then that is what we will use. Then of course we can run into the issue with patients that have underlying renal disease that may not tolerate the nonsteroidal and we’ll have to work with that patient, with that drug and how often to give it, and if we can safely give it and try to balance as best we can, the different diseases.
Dr. Andy Roark:
Okay. So, start first line…probably nonsteroidal, things like that. Is there a place or so what makes a chemotherapy candidate? Other modalities that we look at it, I know just, I see some of these dogs that end up on chemotherapy drugs, things like that, is that common? What is the dividing line between patients that we kind of direct in that direction and those that we don’t.
Dr. Sandra Bechtel:
When I have clients present for other options, I always give them different options. I feel like I have that easy job and that I can give them what’s available, what I think would be appropriate options for their pet. But also as a pet owner, I know that the hard job is to actually sit on their side and then actually decide based on a lot of different factors.
Dr. Sandra Bechtel:
Sometimes it’s finances, but sometimes it’s…their pet. Will my dog tolerate coming in every three weeks for chemotherapy or is my dog super frightened or do we have to sedate my cat so heavily every time that we bring my cat in that it’s just not a very good quality of life. Can I actually take off work to bring my pet in for treatment every two to three weeks when it’s recommended? Is that right for my family and other emotional decisions and certainly cancer and chemotherapy that experiences that the family may have had with themselves or close family members or friends. So many different factors go in concurrent diseases, their pet might have. So many different things may go into the decision as to whether or not they would like to pursue chemotherapy that we always discuss it as an option if they would like to be a bit more aggressive.
Dr. Sandra Bechtel:
If their pet is a good candidate based on concurrent disease status, it is something that we recommend because we know that it can, in some cases, help shrink down the primary mass and also delay metastatic disease onset. But we know that it’s not right for every patient or every family. We don’t know which chemotherapy is best to start first. I wish I had an answer on that too. But more recent studies by Debbie Knapp out of Purdue seems to not so much matter, which when we start with, but if we keep switching to different protocols, when they become resistant to different drugs, that those are the pets that seem to do well for the longest. Unlike, lymphoma, when we talk about, once you become resistant to one drug, it seems like every drug we try has less of an effect and the duration is shorter. It seems like transitional cell Carcinoma is not one of those drugs. You still have a pretty good chance of responding to the next drug and responding for quite a while. Each time we try a new one.
Dr. Andy Roark:
Gotcha. That makes sense.
Dr. Sandra Bechtel:
Yeah. And then we also have radiation therapy as an option, and I think we’re returning to that more frequently as well, to try and get a little bit more local disease control to the bladder. As we’re getting better at localizing the radiation to the bladder and reducing side effects to the area, to the normal tissues in the area, we’re seeing better local disease control with the use of radiation therapy as well, but certainly the timing of treatment, the expense of treatment and the time commitment on the part of the owner are going to all be factors and to whether or not they elect to add in radiation therapy as well.
Dr. Andy Roark:
What do you say when clients ask if surgery is an option? When they say can you not, can you just take it out? How do you sort of walk through that with them?
Dr. Sandra Bechtel:
So a lot of it actually depends on the size of the tumor and also where it’s located. Unfortunately most of them are in the trigone or kind of the neck of the bladder area, so it’s not in a place where we can strategically excise it. There are some that are in what we call the apex or kind of that rounded part of the bladder, so it looks like we would be to take it out. Certainly there’s some, actually some papers out there that suggest those patients, where we are able to take it out, that they actually live a little bit longer. Those patients tend to have smaller tumors.
Dr. Sandra Bechtel:
We don’t know if it’s because they have surgery or because they started out with smaller tumors. But we do know, for sure, that those patients are not cured when we take them to surgery and that in the bladder, there’s…this concept of what we call field carcinogenesis. What that means is whatever that one part of the bladder that was exposed to that allowed that tumor to form, the entire bladder was exposed to. So even if we are able to completely surgically resect, the little mass that we can see, we will see other areas of tumor pop up within that bladder.
Dr. Sandra Bechtel:
So we know that surgery is not curative and there are select patients where we might discuss it with them as an option. And they may or may not pursue to elect to pursue surgery. But the majority of patients that we see to be completely honest are not surgical candidates based on the size and number of masses that we see in the bladder.
Dr. Andy Roark:
Yeah. What’s the prognosis that you communicate to the bad owner? As far as the expected amount of time that we can have where we still have quality of life?
Dr. Sandra Bechtel:
So to be completely honest, it depends on the response to treatment. And what we see is across the board. What’s published, if we use a nonsteroidal chemotherapy, can range anywhere from a median says where 50% of dogs are alive and 50% of dogs are, have died due to their cancer can range from about nine ish months to tenish months. But we do see dogs in a large range where we see some dogs that really just don’t respond to treatment at all and have a rapidly progressive disease course. We have some dogs that are one, two, and three years down the road that may have had a little bit of shrinkage, but then sit with stable disease for quite a long time. And because they don’t really have clinical signs, a bladder mass is there and we’re keeping it stable and they feel really good and have an excellent quality of life and it doesn’t bother them. We consider that stable disease a treatment success.
Dr. Andy Roark:
Gotcha. Are there sort of prognostic flags that you look for? When the pet owners come in and they’ve been doing this for, I don’t know, a week or a month and they say, do you think that she’s going to do well? Are there things that you have spotted that you think may indicate patients who are going to respond well to treatment versus those that are not, or monitoring steps where you say, really, this is, this is a monitoring way that we can kind of look and get an idea of the speed of progression in individual cases? Or is it just a crap shoot and you’re like, sometimes it looks bad and then it looks okay and sometimes it looks great at the beginning and then all of a sudden it looks bad?
Dr. Sandra Bechtel:
And cancer does do whatever [crosstalk 21:18:00]
Dr. Andy Roark:
I’m trying to put control where there is no control, but pet owners always look at me and they say, well, how do you think this is going? And I guess I was trying to put that to you and be like, is there any way to tell how this is going once treatment is rolling along
Dr. Sandra Bechtel:
There is and you know, some of it is honest to goodness where the tumor actually is, and if we have the tumor that’s in the urethra, if it blocks off the dog’s ability to urinate, those tend to do poorly just because of the functionality of where it is and our ability to control it. Or if we have one that’s growing near the ureter, so a tube that connects the kidney to the bladder, that can actually cause secondary damage to the kidneys. That tends to be problem just because of where it’s located. So even if I can stop it from growing for a little while, it’s still in a problematic place. Those are the ones that tend to go poorly because it’s harder for me to manage, even if I can stabilize it, if that makes sense.
Dr. Sandra Bechtel:
So those that are in bad places tend to do worse just because they’re harder to manage. Whereas those that are in less bad places, if I can have them stabilize or even shrink a little bit, then I can provide that good quality of life for the patient. Then I can do what I want to do and give them a really good quality of life. Whereas that tumor that blocks the urethra, even if I make it shrink a little bit, that dog is still very uncomfortable and I’m not providing the quality of life that I want to provide. Then we start talking about things like urethral stents, which are then quite expensive and cause incontinence, and there’s a whole nother realm of possibilities and things that we need to discuss.
Dr. Andy Roark:
When do you start get into that conversation of urethral stents? Because we’re going way down the rabbit hole at this point, but do you offer that to every client or is it a certain type of owner that you feel like is the ones who are up for this? I can’t imagine it’s something that most pet would be excited about. How do you make that distinction?
Dr. Sandra Bechtel:
It’s not something we actually do that often. That’s because it does have its own set of side effects and it is quite expensive and we only would use it in the face of a urethral obstruction. If the bladder mass is in the trigone, or in the bladder neck, and it’s causing an obstruction, then an urethral stent is not necessarily going to be helpful. But if it’s in the urethra and causing an obstruction, we may not have a choice other than to offer a stent just to relieve that obstruction. We may be at a decision making point where we say you know what, we can offer a stent to relieve the obstruction, or we may be at a point where we need to consider euthanasia because chemotherapy is just not going to work fast enough to provide your dog comfort. If we do a stent, it comes with its own set of complications.
Dr. Sandra Bechtel:
Unfortunately it can cause incontinence in quite a few dogs. And it also, because you’re opening up that urethra, makes them more susceptible to urinary tract infections in a dog with a bladder tumor that’s already a little bit more susceptible to urinary tract infections. It’s not right for a lot of families. It’s not the right answer and that’s okay because we’re not talking about something we’re going to cure. I’m not going to say we’re going to place this stent and your dog is going to go home and be happy for five years. It’s a short term solution. It’s a short term bandaid. We’re talking maybe weeks to months with that bandaid, so to speak. It’s important that if we are going to go that route, that we are all on the same page with what we expect the results to be.
Dr. Andy Roark:
Yeah. No, that setting of expectations is important. That all makes sense. I think I’m ready to have this conversation. I think I have what I need. Are there any last pearls of wisdom or pitfalls to avoid that you would remind me of?
Dr. Sandra Bechtel:
I think the biggest things are I generally, to be completely honest, don’t put a whole lot of stock into minimizing breed predispositions for cancers, except for transitional stock carcinomas because that’s one that you can’t really see. You can’t palpate it but it’s one where I think we should become suspicious of it with those signs of a urinary tract infection in an older dog of this specific breed that hasn’t had these issues before. Chances are if you have a Scottish Terrier owner whose dog comes in with a urinary tract infection, you’re going to mention transitional cell carcinoma and they’re probably going to get annoyed because they already know.
Dr. Andy Roark:
Yeah. They’ve been told since that thing was a puppy. Someone looked at their beautiful nine-week old puppy was like, you know they get transitional cell carcinoma. I don’t know why people do that, but they totally do.
Dr. Sandra Bechtel:
They do. So this is one of the few types of cancers where I think being aware of the breed predisposition is helpful because you can’t really see or palpate it. It’s like the lymphoma breeds. You’re going to palpate and you’re going to work it up regardless of what breed the dog is. A dog is limping, you’re going to work up that dog for limping, regardless of what breed it is and whether or not it gets osteosarcoma. For a bladder, it could be a little bit trickier. I think this is one of those cancers where its worthwhile just to kind of have it in the back of your head. This is a Sheltie, I treated a urinary tract infection, but it came back right away. Maybe I should think about imaging the bladder a little bit earlier than I would in maybe a mixed breed dog. I think that’s a good pearl of wisdom.
Dr. Sandra Bechtel:
The BRAF test is a nice non-invasive test for confirming a transitional cell carcinoma. I’ve done a lot less diagnostic catheterizations since that’s come onboard and that’s nice. I do like to use urinary catheterizations for collecting urine on these guys for cultures and analysis when it’s feasible and to avoid cystos when possible.
Dr. Andy Roark:
Gotcha. That totally makes sense. Well thank you so much for being here. I really appreciate your time.
Dr. Sandra Bechtel:
Thank you for having me. I love coming and speaking with you.
Dr. Andy Roark:
Guys, that’s it. That’s my episode. That’s what I got for you. I hope you enjoyed it. I hope you got something out of it. I love talking to Dr. Bechtel, she’s brilliant and go Gators and all those sorts of things. Thanks again to cruise for making this episode possible. You guys are wonderful to work with, and I really appreciate your support so that we can do these podcasts. They are great guys. Anyway, gang, let’s meet up again and do this soon. All right. Take care of yourselves. Be well, bye.
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