It is selfish to want myself back again?

One man’s question prompts an understanding of when enough is enough and one couple’s decision to stop treatment.
I have always said that every patient’s journey with cancer is personal. Each case is vastly different. The spectrum of patients’ responses to androgen deprivation therapy (ADT) is astounding. For some men, the side effects are barely noticeable and they are endured like a few nasty mosquito bites in summer. Others are driven to near despair and disability by the side effects. Most of us swing like pendulums somewhere between the two extremes. Outsiders, with the big exception of our caretakers, cannot comprehend what it’s like.

My first correspondence with Laurie and her husband, Rommie was in December as I was was coming off of my radiation treatments. (Funny how we now measure time, isn’t it?) Laurie and her husband were working to start a prostate cancer band. Just two quarterly shots into ADT, I was a mere newbie to the Lupron experience back then.

Last week, I heard back from Laurie. She shared with me that Rommie has decided to stop his hormone therapy, that he can no longer endure the hard-hitting side effects he has experienced. In short, he wants to be the person he was before treatment started.

As I read Laurie’s email, I fought hard to hold back the tears. I can’t say I won that battle. I related, in part, to Rommie”s thinking. Admittedly, I have on more than one occasion, wondered why one endures this treatment if there is no guarantee of a positive outcome. Such thoughts can creep up when one’s emotional stock runs low. Although speechless, I was taken by their courage.

Once I had a moment to digest the correspondence and collect my thoughts, I wrote Laurie back and asked if I could share her letter here on the blog. She and Rommie replied with a quick yes, so here it is. It underscores my belief that on this journey, there are no right or wrong answers–only the need for understanding and support.

Rommie and I met in 2005 at the young age of 51. We both had previous marriages, that ended. I raised my five kids on my own in CA after a 20 plus year marriage. Rommie has three children and lived in NV when we first met. I had gone back to school and during one of my evening classes my young classmates told me I should consider online dating. After all, I was the director of my own licensed daycare…my choices were nil and oh yea–they were all young married couples! But I went to Perfect where I met Rommie. I was hooked by his sense of humor in his very first response back to me.

Rommie had spent 12 years in the Navy and worked on airplanes as a corrosion control specialist. He didn’t think he had a chance at dating again, because he wasn’t the refined business man with all the fancy credentials and assets in life. Our first date was magical, spent the day at Dana Point, CA watching the ocean and talking about our entire lives. His heart was so big, and he was such a good man who thought he might not measure up because he drove a truck. I laughed and said measure up to what? You know that saying…at the end of your life, does anyone say, I wish I could spend one more day at the office? No…it’s one more day to be with those you love, and doing what you love. Career and economic status didn’t matter to me at all. A good man, a hard worker, the Heart of a Man was what I was looking for. I found him!

Then, in June 2009, Rommie was diagnosed with prostate cancer. He was put on the hormone therapy prior to radiation. A three-month Lupron shot was his first treatment. He then underwent 43 treatments of radiation and finished two days before Christmas. He has been on ADT since. He just landed a new welding job and works 10-12 hours, comes home with his rear dragging, we have dinner together, and he falls asleep. The fatigue has been grueling, then the insomnia rears it’s head at the wrong time…he never had any problems sleeping at night. That is just one of the negatives he has been dealing with. We are both 57 now and we know there are many, many more years left.

Hopeful? Yes! Optimistic?! Of course…you must be.

Although is hormone therapy devastated him, and Rommie never once complained.

But finally, he came to me one night, riddled with some guilt and feeling a bit selfish, and said, “Let’s talk about something important.” After 43 rounds of radiation and in the last phases of ADT and witnessing too many side effects and changes to his person, I was prepared for anything. Rommie told me, “it’s time to stop the shots, I can’t do it anymore, honey.”

I just sat there and listened. He went on to say, “…whatever the first shot did to keep my prostate small and prepare me for the radiation, probably did the best job it could. I think I have been zapped enough, for now.” He explained, “I feel like I have morphed into something, someone that I don’t know… something that doesn’t feel good, that keeps shouting for the real guy to come back. ” He said, “I have been zapped, fried, targeted, and tattoo-ed. I have grown larger breasts than our daughters and my hot flashes rival all of your friends. I have coped with depression, taken the medication and still fall to my knees with a despairing feeling of remorse. I get foggy headed over nothing, and can’t remember why because of the memory loss.”

By that point, my tears started streaming down my cheeks. He held my hand and looked at me, really looked AT me and said, “I want, no I need, to live my life with you and for US, again, the best way I can, without the rest of these chemicals that deter me from living a better life.” It’s not that he doesn’t believe in medicine, and its great power to heal, it’s just that he believes in a chance to live a better life right now.

He asked, “Is it selfish of me to want myself back again? ” He asked me if I would support this decision and still love him. I am his wife, partner, lover and friend. The quality of life for my husband and thousands of others, hanging on a thread of hope, promise, uncertainty, or faith in miracles is not for me to judge, but to pray and support their own decisions about their healthcare. I believe in greatness, and I have tremendous faith and hope that good will prevail. I am the glass half full person, and my husband has always been a believer of the glass half empty. So when Rommie decided to live his life with a “full glass” I cried for his courage, bravery and moment of reckoning. Men know their numbers, and that’s what got to him after a while: Gleason 8, stage 3…he said “I am much more than that.”

He bought a bike and soon I will get mine. We are eating healthy, choosing to exercise more, and learning to live with less stress. We are also staying positive, maintaining a more optimistic outlook, which is believed by many to change the structure of cells for the better.

It’s not rocket science but it is our human experience that makes us live better lives. Ironically the ADT was causing tremendous stress, something cancer doesn’t need. I just wanted to share this with you, and hopefully let others know, they aren’t alone with these thoughts. It’s a gamble…life can be a crapshoot of sorts and we don’t recommend this decision for anyone else. This is what Rommie has decided for his own health, and for our lives together. He wants to breathe in life every day and live it the best way he chooses. He says he feels so “free” for taking back his life again.

Will this new attitude beat his cancer any better than continued treatment? Who really knows? But it will improve his chances to be happier, more productive, and live a more fulfilling life. He knows what is most important, and I support this great guy, for being true to his feelings.

Thank you, Dan, for your interest and support. A group hug back to you! Love and prayers for you too. — Laurie and Rommie.

Bless you, Laurie & Rommie. Our prayers are with you.

Reassuring Stories From the Hood

35 years after leaving my hometown of New Hyde Park, New York, two recent connections provide positive examples of survivorship and optimism.


It’s funny how life works. Sometimes you can’t see what it is up to unless you step back and make a conscious effort to “see the the forest for the trees.”
Several weeks ago during my evening commute, GE7-36… came to mind out of nowhere. I was intrigued by the random appearance of this alpha-numeric sequence. I recognized the combination of letters and numbers as the beginning of the phone number of my very good friend from elementary school, Michael. Through the years and life’s hectic pace, I had lost touch with him. In the past year or two, Facebook and Google searches provided no clues as to to his whereabouts. I never imagined that I could use the same telephone number I used to call him 42 years ago. GE7-36… GE7-36… GE7-36… Like some code breaker in Mission Impossible,my mind kept repeating the sequence until finally, the last two digits fell into place, pulled from the recesses of my mind. I smiled. Considering the games Lupron can do to my short-term memory, this seemed a momentous achievement.

No time like the present, I thought to myself and voice dialed the number. Within minutes, I was back in touch with my friend and learned that he was in his childhood home taking care of his father who has been battling recurrent prostate cancer for nearly 20 years. In a small world moment, I learned that his father has been receiving treatment all this time at Memorial Sloan-Kettering Cancer Center in Manhattan–the same center with which I have regular contact in my professional role. Michael’s father, now in his 80s, is doing well. While his survivorship has no doubt had it share of challenges, he remains an active gentleman who is able to enjoy life with his family.

Following a lengthy catch up session and exchange of email info, I hung up. I realized that I had not only reconnected with a old friend, but I was given a strong reminder that even many cases of recurrent cancer can be managed with positive outcomes for many years.

Last week, another connection to my hometown was made. As I scanned my morning prostate cancer news roundup, I noticed a New Hyde Park Patch Volunteer Profile on Don Pospisil, a prostate cancer patient who has been cancer-free since his diagnosis and surgery 16 years ago. The story was an upbeat report on life after prostate cancer and Don’s commitment to the Make A Wish Foundation on Long Island. I immediately contacted Don and asked him to share his story. I believe it can boost the hopes of many. All too often, us patients can get stuck in neutral. (See: A Shift Out of Neutral) Here is Don’s contribution:

It all started in the spring of 1995 when I was 44 years old and started to get recurring prostate infections. I went to my regular doctor who referred me to an urologist. After going for tests all he could tell me was: “I can’t say you do have cancer and I can’t say you don’t have cancer”! Well that wasn’t too reassuring so my regular doctor referred me to another urologist, Dr. Waldbaum who was head of Urology at North Shore Hospital at the time. Dr. Waldbaum then referred me to one of his associates–Dr. J. Steckel.

Dr. Steckel did all the tests as well. He found that my PSA level was 4.5 and after doing the “finger test” suggested that he should further examine my prostate and take a biopsy. After this procedure, the Dr. Steckel said to me “Don’t worry – you’re too young to have prostate cancer”! Well this really sounded reassuring to me until one week later when he called me with the bad news – yes, you do have prostate cancer.

Well the news was quite devastating–nobody wants to be told they have cancer! But, it wasn’t all bad news. The doctor said the cancer was caught very early. I then had my cancer consultation with the doctor in which my options were laid out. My three options were: 1) I could just wait to see if it got worse–not an option in my book, 2) Have radioactive seed implants–the downside of this treatment was that if the radiation didn’t get every cancer cell the cancer could come back and possibly be all but impossible to cure. So, I didn’t like that option either. The final option was a radical prostatectomy which scared the heck out of me. But after the doctor assured me that he could do a “nerve sparing” prostatectomy and that I would still have a normal sex life afterwards (except I couldn’t have kids any more, but that wasn’t a problem for me) made me feel a little better. He also assured me that by removing the entire prostate he would get all the cancer because the cancer was confined to the prostate and hadn’t spread. And, he said that since the cancer was caught so early I didn’t need the operation until September.

I must admit it was a long summer that year, but my wife did a great job keeping me going for the next three months, and we had a great summer together, even touring Hawaii. On September 8, 1995 I had the operation. I won’t say the operation was a breeze–it was painful, and wearing a catheter for 2 weeks wasn’t easy either. The first week was the hardest, but it got easier as time went on and after three weeks of recuperation I was able to return to work. Within six weeks I was back to jogging and feeling pretty much back to normal. So, the advice I would give to other men today is to make sure to have a PSA test done after age 40 not 50 like some in today’s medical community advise. It was only because I had a symptom that I had a PSA test done and that’s how my cancer was discovered. I’m sure there are men out there who do not have symptoms but could still have prostate cancer, so that’s why this test is so important. In closing, I must also say that having a very good experienced doctor is also important. I can say without a doubt that Dr. Steckel was excellent, and truly I owe him my life, not only for finding the cancer but also for doing a fantastic job removing it!

I am no longer surpised by the confluences of life. I just enjoy keeping an eye open to see them appear. Thank you Don for sharing your story. We love hearing stories like yours! All the best to you and your family.

Treating the Treatment with My TEAM

Armed with an expanded list of prescriptions, I find relief and the answer to the question: Who should be the primary care coordinator for cancer patients?


I abide by the adage that it takes a village to raise children. I now fully appreciate that it takes a team to care for cancer patients. My epiphany came during the same week that some cancer advocates in my network were debating whether a patient’s oncologist, urologist or internist should be the primary treatment navigator. Just two days ago, I added my two cents to the debate saying via an email that I wouldn’t give up my oncologist as my treatment point guard for anything. I still wouldn’t. But, as owner of my cancer franchise, I  know first-hand how crucial it is to have a well practiced team that knows how to win a passing game.

Using my past few weeks as example and a few more basketball analogies…

1. Experiencing severe and highly unsettling palpitations, I emailed my oncologist (my point guard) for guidance. He passes the ball immediately to my internist for an EKG and preliminary assessment. In basketball, the point guard is also known as the team’s floor general and the best ball handler on the team. In football terminology, the point guard is a basketball team’s quarterback. The point guard is essentially the team’s captain, and his/her job is to make his/her teammates better and to hand out assists. At this point in my journey, I see my oncologist as the one who is going to make the fantastic scores against cancer and play a pivotal role in directing the team to victory.

2. Upon reading my EKG and spotting an aberration, my internist (my shooting guard) passes the ball to a cardiologist. Shooting guards can also be the team captain as well. A quality shooting guard should be able to consistently hit 20-foot jump shots. Besides being able to shoot the ball, shooting guards must also have good ball-handling skills because they have to be able to create their own shots off the dribble. They should also be able to make good passes.

3. After ordering a complete set of cardiac tests, my cardiologist (my power forward) quickly assess that, with no underlying cardiac disease, there is no point to be made from his vantage spot on the court and passes the ball back to my internist for the next play. A power forward plays a role similar to that of the center, down in the “post” or “low blocks”. On offense, he can “post up”, playing with his back to the basket, or set up for mid-range jump shots. On defense, he plays under the basket in a zone defense or against the opposing power forward in man-to-man defense.

4. In a scramble of appointment schedules (my quarterly oncology appointment happened to come first), the ball gets relayed to my point guard (oncologist). He is able to make an advance by writing a prescription to calm the increasing severity of my hot flashes. Then, to best score against the palpitations, he hands the ball off to the shooting guard (my internist) who is able to make a wide assessment the my current field of play and prescribes a mild medication that will hopefully score a winning point against my racing heart. In this process I had been working with a new internist. He was called off the bench and into the game because of the new schedule and sporadic availability my internist of three years. Impressed by the new player’s skills, I (as owner of the team) made the decision yesterday to move him into the first string.

Now, I admit my basketball knowledge is shaky a best. But I use the analogy to make a point. Assign what ever positions you like to your cancer team. Just remember that every cancer patient is different and every game is different, requiring a complex set of moves, expert decisions and passing. As owners of our individual cancer franchises, we need to build and manage a team that we trust. It must have an uncompromising commitment to teamwork–constantly communicating and passing for the best advantage. Only then can it ultimately claim a win for us.


Laying Off the Lupron

There’s new hope for us side-effect-crazed patients.


During the discussion with my cardiologist this month he said: “You have to admit, there are a whole bunch of negatives with Lupron and androgen deprivation side effects… but then again, you have to love the upside.”

Love it? I might not be able to live without it! I thought to myself. It’s the obvious upside that keeps me and thousands of other men trudging through the Lupron gauntlet everyday. I also love that he gave my heart a clean bill of health despite my heart-choking side effects of ADT.

Now, there is promising news that may help many men like me better manage their treatment and possibly their side effects. In my mind, it’s nothing short of a game changer for clinical practice.

At the American Society of Clinical Oncology meeting last month in Chicago, a presentation on Intermittent Androgen Deprivation (IAD) was selected for a Best of ASCO merit. The big news for us patients? Data from a study out of Canada showed that shorter, intermittent eight month cycles of IAD can deliver clinical outcomes that are comparable to continuous androgen deprivation (CAD) for patients whose PSA levels rise to 3 ng/ml or more but whose scans show no metastatic disease (detectable lesions in bone or soft tissue). You can read more about this development in my piece: IAD: Changing the Standard of Care for Men with Recurrent Prostate Cancer.

Needless to say, I find this development VERY encouraging. During my last visit to my oncologist, he spoke of pulling back on my ADT from three years to two years. While my emotions jumped at the idea, I have to admit I was wondered just a little if I would be giving anything up… taking any unnecessary chances. This latest development gives me a heightened sense of confidence with the revised thinking. And, truth be  told, one more year of this most unusual existence is much more palatable than two.

Of course, when I see Dr. Lowe for my quarterly exam next week, I will also be discussing this study to see if, in his opinion, we need to make any further revisions to our plan. My guess is, as this is my first run with ADT, that sticking with two years might be best and that we can assess if IAD is the way to go should my PSA levels start to rise in the future. I need to leave that with my oncologist to consider, but it’s definitely worth asking the question.

Finally, I see some light at the light at the end of the Lupron tunnel.

As I push the “Publish” button on this entry, I am wondering how many other men reading this will be encouraged to consult with their doctors about IAD? I am interested in hearing your thoughts.

Lupron Patients report side effect

By luck of the draw, I’m one of them.


Most who have been inducted into the Lupron League know that life without testosterone is a crazy and trying proposition. While not at all pleasant (except for the laughing fits…), I thought I had started to make peace with this drug and its hold on my day to day life. But, just as I was counting down the days to the one year down, two to go mark, I started to feel them. Palpitations.

After the first few occurrences, I thought perhaps they were simply an aberration–something that would go away as simply and quietly as they had arrived. But they didn’t. Their frequency and severity increased over a two week period. Soon they began to feel as if someone was grabbing my heart and trying to choke the miracle muscle mass. These sessions came more frequently in the afternoons and evenings. If they came at bedtime, it was difficult to fall asleep. They grew more distressing in a sleep position. There were no other indications to make me think that a more serious condition was looming. But, considering one percent of patients do experience cardiac arrest, I did monitor these episodes very closely.

Two weeks of increasing discomfort convinced me that these wild palpitations were not going away anytime soon. My wife didn’t even need to nudge me. I called and saw my internist last Friday, just before the start of the July 4th holiday weekend.

An EKG revealed that there is an abberation that wasn’t there in November when I was just three months into treatment. My internist described it as a dip in my lower left section. Um…dipping when it should be lifting, I suppose my heart is no candidate for Beating with the Stars at this point. I left the doctor’s office with a referral to a cardiologist for this coming Friday, a prescription for nitroglycerin tablets (they do help reduce the pain of these episodes) and a reminder to go immediately to the emergency room should I experience any new symptoms that give me cause for concern. I was also given a prescription for a more effective statin because, despite my much improved diet, Lupron has also driven my cholesterol back into the area of concern.

I left the doctor’s office and had a sizable come apart sitting in my car in the parking lot. While it’s nice to have identified a possible suspect in this case, it is still disconcerting and unsettling. One close friend responded by saying how awful it is to have to deal with this new dimension of treatment. I for one, couldn’t disagree. But when I thought about it futher, I realized that I can take awful. It’s the slow water drip of bad news that is wearing on me. More blood draws, more specialists, more tests and, most likely, new treatments to counteract the effects of my treatment!

Once again, I find myself making mental justifications for the sake of my outlook… most likely, it’s only an arrhythmia and just a few missed heart beats, right? Gee…, I’m lucky to be in the five percent and not the one percent… I am looking forward to my appointment with the cardiologist on Friday and hope we can take care of this issue with speed and ease. I also hope that I am right and he doesn’t find anything else. My need to tackle this and push it into a manageable box is running high.

Just two weeks ago, I met Rick, for the first time. He is a fellow Lupron patient and advocate. He also runs support groups for patients in Marin County. He adamantly vented that medical teams do not prepare patients adequately for dealing with the down side of Lupron and androgen deprivation therapy (ADT). While I know that some men are fortunate enough to sail through ADT with few side effects, I’m sitting here remembering Rick’s words and thinking, truer words were never spoken.

PSA testing on seniors

We Often Consider at What Age a Man Should Consider PSA Screening, But We Rarely Ask When Do Individuals Stop?

I just had an interesting conversation with an individual who asked me at what age do most men start thinking about NOT having an annual PSA test? To be honest, I didn’t have an immediate answer. It’s a complicated question and I am, to be honest, stumped. Age is certainly a factor as is the reality that there exist 24 types of prostate cancer that range from indolent to very aggressive.

We frequently read about suggested guildelines for PSA screening. I personally like the AUA recommendation that suggests a man should talk to to his doctor about a first screening to establish a baseline when he enters his 40s. From there, based on a man’s general state of health and family history, he can decide on a screening approach that is right for him.  But in the almost twelve months that I have been writing this blog and the years that I have been meeting fellow patients, I can’t remember a discussion that addresses the other end of the spectrum. I would think that a vibrant, active 78-year-old man with a form that appears to be aggressive would be grateful to have the data and take some sort of action. Of course, a man of the same age could be pleased to live out his life with little or no intervention if his numbers indicated a slower growing form of cancer that he could quite possibly live with.  But, how many give up, for whatever reason, wanting to know at all?

So, I have to ask four questions:

1.) Are there men out there in their 70s and 80s who choose to no longer have annual PSA screenings and why?

2.) Are there men out there in their 70s and 80s who insist on annual PSA screenings?

3.) Are there men in this age group who have been screened and diagnosed with cancer?

4.) If you were given a diagnosis of cancer in your 70s or 80s, what course of treatment did you decide upon?

Thank you to anyone and everyone who can provide some insight.

Treatment is a Complex Issue

The following is a a guest entry I wrote for KevinMD, one of America’s top ten leading medical blogs. It ran this morning.


As a patient, I feel for anyone who is given a diagnosis of prostate cancer.  Hearing the “Big-C” word can be upsetting enough. But the complexity of the disease—diagnosing it, trying to characterize it and selecting the appropriate treatment—can feel like insult upon injury.  We need to talk about prostate cancers. With 24 known sub-types of this cancer—from non-life-threatening to very aggressive—it’s no wonder so much time is expended on debating PSA screening and the potential for overtreatment.

While debates continue, more than 32,000 American men die from this disease each year, placing it on par with breast cancer in incidence and mortality.

Oddly, I still contend that when I was diagnosed last year, I was “lucky” enough to have clear diagnostic and prognostic data to inform my decision to have a radical prostatectomy, despite potential side effects .  My PSA had nearly doubled in a year’s time. As my urologist reviewed my biopsy results, the extent of the cancer’s involvement in my walnut-sized gland and my Gleason scores, I knew where I was headed. He dutifully began sketching out all treatment options currently available to patients when I told him to stop and move to the top two options. He gave me a dubious look before I shared with him that I had learned much about the disease in two years of working at the Prostate Cancer Foundation.

I was lucky once again when my surgeon’s professional instincts prompted him to remove some of my lower lymph nodes during my robotic procedure, something that’s not always done.  The post-surgical pathology report upgraded my diagnosis to Stage 4 metastatic disease with single Gleason 5 cells discovered in the nodes. (Not exactly the kind of upgrades I am accustomed to in my life…) As a result, I headed into seven weeks of radiation therapy and three years of androgen deprivation therapy—a palliative treatment that drastically cuts my production of testosterone, a fuel for prostate cancer growth and proliferation.  Today, I have a 60 percent chance that I will have to live with recurrent disease. I look forward without second guessing.

Not all patients have such clarity. Through My New York Minute, I meet many readers who are confused by the complexity of this disease. As a fellow patient who also works for world’s leading private accelerator of prostate cancer research, I remind them:

  1. The PSA test is not a cancer test—it’s a diagnostic tool for identifying potential problems, including cancer, in the prostate
  2. With 24 sub-types of this cancer, one size does not fit all for treatment
  3. Sometimes, the best treatment is no treatment and proactive surveillance
  4. Age and personal preference are important factors in treatment selection
  5. Once committed to a treatment plan, avoid the pitfall of second guessing

Science will someday, sooner than later, enable us to identify which prostate cancer a patient has and prescribe highly personalized treatments that will work best for their case. Until then, an in-depth understanding of the disease and the advice of a trusted healthcare professional remain the best tools for making treatment decisions with confidence.

The Power of a Moustache

It’s surprising how landmark deep science can be supported by deeply rooted fun like Movember.

Researchers have sequenced the genomes of prostate tumors from seven men–a landmark event that promises to one day help clinicians learn how to differentiate between those tumors that will be highly aggressive and require immediate treatment and those that are essentially benign and that can be simply observed through proactive surveillance. This project represents a transforming moment in understanding the underlying biology of prostate cancer.

Geneticists have been sequencing a variety of tumors of different types, but the effort on prostate tumors introduces a new level of complexity.  If the data for each genome were presented in the form of a printed telephone book, it would form a book 35 feet high.

All of this is deeply complicated science, indeed. And it’s promising news for millions of prostate cancer patients. But it is important to note that is was made possible by an entirely fun–even frivolous–annual campaign known as Movember. Each year, thousands of men around the world grow moustaches to raise funds that support crucial research that can ”change the face of men’s health.” In the case, whole genome sequencing of prostate cancer was made possible by unrestricted funds raised by Movember in the U.S. and donated to PCF.

What really surprised the researchers, said geneticist Levi Garraway from the Dana-Farber Cancer Institute, was the wholesale shuffling of large segments of the genomes, with relatively big chunks of DNA broken out from one site and reinserted elsewhere. The team found more than 100 such rearrangements, far more than had been observed in any other form of cancer studied so far. “Not only were they much more common than one might have imagined, but there were certain patterns,” Garraway said. “It’s important for prostate cancer, but it might be telling us something fundamental about how cancer genomes become messed up in the first place.”

Complete information on this historic sequencing of whole prostate cancer genomes can be found at PCF’s website.

Men of America: Grow on!