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i repeat a question

Forums General Melanoma Community i repeat a question

  • Post
    tkoss
    Participant
      ed, bubbles, others with tremendous knowledge and experience, i ask this question again. the last time i asked the responses were meager.

      what is the issue of Immo and covid?
      my docs can’t or won’t give me an answer. the web says little.

      does taking Nivo make me more likely to die from Covid whilst doing infusions? After my last infusion, how long is my immune system supercharged so that i remain at high risk of death from Covid.

    Viewing 4 reply threads
    • Replies
        Bubbles
        Participant
          The bottom line, Tkoss is – we don’t know. Here are two differing opinions – Here is the link to one:

          https://www.oncnursingnews.com/web-exclusives/immunotherapy-does-not-increase-death-risk-in-patients-with-covid19#:~:text=Treatment%20with%20immune%20checkpoint%20inhibitors,%3A%20COVID%2D19%20and%20Cancer.

          This link states:
          Immunotherapy Does Not Increase Death Risk in Patients With COVID-19 RACHEL NAROZNIAK, MA Wednesday, July 22, 2020

          Treatment with immune checkpoint inhibitors (ICIs) did not increase the risk of mortality in patients with COVID-19 and cancer, according to findings from a multicenter, retrospective analysis presented during the 2020 AACR Virtual Meeting: COVID-19 and Cancer.

          Data showed that the mortality rate of patients with COVID-19 and cancer who received immuno-oncology agents was 8%. “This rate is similar to the mortality rate in the general cancer population, which is reported to be in the range of 7.6% to 12%,” lead study author, Aljosja Rogiers, said during the medical meeting.

          Nine of the 113 patients included in the study population died, however, none of these deaths were attributed to treatment with checkpoint inhibitors. All patients who died on study had advanced cancer; 7 died due to COVID-19.

          The analysis by Rogiers et al analysis included data from 113 patients with laboratory-confirmed COVID-19 from 19 centers across North America, Europe, and Australia who received immunotherapy within 12 months of testing positive for COVID-19. Most patients (82%) received 1 anti–PD-1 or PD-L1 agent; 13%, an anti–PD-1 agent in combination with an anti–CTLA-4 drug; and 5%, another immunologic therapy. None of the patients were treated with chemotherapy. Data points included symptoms, comorbidities, and medications, in addition to investigations and treatments implemented for COVID-19. Investigators assessed the following outcomes: hospital and intensive care unit (ICU) admission and mortality.

          The evaluation was conducted to shed light on the clinical implications of immune checkpoint blockade. “To what extent immune checkpoint inhibition [affects] COVID-19 infection in patients with cancer is unclear. Theoretically, inhibition could either mitigate or exacerbate COVID-19 infection. This study was designed to help us answer this question,” said Rogiers, a fellow at the Melanoma Institute Australia, in Sydney.

          Patient Characteristics

          At the data cutoff of May 15, 2020, the median age was 63 years (range, 27-86) and the majority of patients (65%) were male. Few patients had an ECOG performance status of 2 or greater compared with 0 to 1 (10% vs 90%). Regarding the geographic regions to which patients belonged, most of the patients included in the analysis were from Europe (64%). North America and Australia accounted for 33% and 3% of the patient population, respectively.

          Sixty percent of the 113 patients were symptomatic for COVID-19. Having contact with someone who was COVID-19–positive provided the rationale for testing the asymptomatic individuals included in this study, Rogiers said. Among the symptomatic patients, fever (68%) and cough (59%) were the symptoms of COVID-19 witnessed, followed by dyspnea (34%) and myalgia (15%). Beyond diabetes, which affected 15% of patients, the comorbidities that investigators observed were of a cardiovascular (27%), pulmonary (12%), and renal (5%) nature. When investigators examined the use of immunosuppressive agents used in this population, they noted the use of 10 mg or more of prednisone per day in 13% of patients, and use of another immunosuppressive agent in 3%.

          Fifty-seven percent of patients had melanoma; 17%, melanoma; 9%, renal cell carcinoma (RCC); and 17%, another type of cancer. Most cases were treated in the advanced/metastatic setting (74%); 26% were addressed with a neoadjuvant treatment intervention. Reponses to therapy were as follows: partial response, complete response, or no evidence of disease, 30%; stable disease, 18%; progressive disease, 15%; not available, 37%.
          Hospital, ICU Admissions and Mortality Outcomes

          Twenty-nine percent of patients were admitted to the hospital, where antibiotics, oxygen therapy, glucocorticoids, antivirals, intravenous immunoglobulins, and anti–interleukin-6 agents were administered to 25%, 20%, 10%, 6%, 2%, and 2% of patients, respectively. Five percent of patients were admitted to the ICU, where were put on mechanical ventilation and vasopressin (3%; 2%). One percent underwent renal replacement therapy.

          Results from the outcome concerning hospital and ICU admission showed that 61% of patients were discharged, 12% remained in the hospital, and 27% of those admitted (9 patients) had died by the data cutoff. Data from the mortality outcome assessment demonstrated that 92% of the 113 patients were alive and 8% (9 patients) died.

          “Median age of the patients who died was slightly higher [than in the general population,” Rogiers said, citing the median as 72 years (range, 49-81). Among the patients who died, 2 had melanoma; 2, NSCLC; 2, RCC; and 3, another type of cancer. “Although the numbers are small, they may indicate that COVID-19 has a slightly higher mortality rate in patients with non–small cell lung cancer than melanoma, given that 57% of patients had melanoma and 17% of patients had non–small cell lung cancer,” he added.

          Seven of the patients who died were treated with an anti–PD-1 agent. The other 2 patients received a combination anti–PD-1 and anti–CTLA-4 regimen.

          Reference
          1. Rogiers A, Tondini C, Grimes JM, et al. Clinical characteristics and outcomes of coronavirus 2019 disease (COVID-19) in cancer patients treated with immune checkpoint inhibitors (ICI). Presented at: 2020 AACR Virtual Meeting: COVID-19 and Cancer; July 20-23; Virtual.

          This article was originally published on OncLive as, “Immunotherapy Use Does Not Correlate With Increased Mortality in Patients with COVID-19, Cancer.”

          Bubbles
          Participant
            The second link: https://www.medpagetoday.com/infectiousdisease/covid19/87263

            It states:
            Cancer Immunotherapy Tied to Severe COVID-19 Outcomes — Nearly threefold increased risk of hospitalization, severe respiratory illness
            by Ian Ingram, Deputy Managing Editor, MedPage Today June 25, 2020

            Cancer patients receiving immunotherapy were at increased risk for severe outcomes from COVID-19, according to retrospective findings from Memorial Sloan Kettering Cancer Center in New York City.

            Among over 400 cancer patients with symptomatic COVID-19, those treated with immune checkpoint inhibitors saw a nearly threefold risk of hospitalization (HR 2.84, 95% CI 1.24-6.72, P=0.013) and severe respiratory illness (HR 2.74, 95 CI 1.37-5.46, P=0.004) in a multivariate analysis, Mini Kamboj, MD, and colleagues from Sloan Kettering reported.

            In the 35 patients with lung cancer, higher rates of hospital admission and severe respiratory illness were seen for those on immunotherapy (83% and 58%, respectively) compared to those not treated with these agents (52% and 35%). To a lesser degree, this pattern was seen among patients with other solid cancers receiving immune checkpoint inhibitors as well.

            Writing in Nature Medicine, however, they cautioned that treatment decisions regarding these anticancer agents in patients with symptomatic COVID-19 should not be altered without further evidence, and recommended increased testing to ward of potential infections in this vulnerable population.

            In contrast with earlier reports, there was no increased risk of worse outcomes among patients undergoing chemotherapy within 30 days of their COVID-19 diagnosis, and major surgery and metastatic disease did not predict worse outcomes.

            “If you’re an oncologist and you’re trying to figure out whether to give patients chemotherapy, or if you’re a patient who needs treatment, these findings should be very reassuring,” co-author Ying Taur, MD, PhD, said in a press release.

            On multivariate analysis, patients with hematologic malignancies had an increased risk of hospitalization (HR 2.49, 95% CI 1.35-4.67) and potentially severe respiratory illness as well (HR 1.79, 95% CI 0.97-3.32), in line with a previous report showing higher mortality in this group.

            Non-white race (HR 1.62, 95% CI 1.05-2.51) and chronic lymphopenia or corticosteroid use (HR 1.85, 95% CI 1.06-3.24) were also significantly associated with an increased risk of hospitalization.

            “The course and clinical spectrum of this disease is still not fully understood and this is just one of many studies that will need to be done on the connections between cancer and COVID-19,” Kamboj said in the statement. “But the big message now is clear: People shouldn’t stop or postpone cancer treatment.”

            For their study, Kamboj, Taur, and colleagues examined 423 cancer patients diagnosed with COVID-19 at Memorial Sloan Kettering from March 10 to April 7. A majority of patients were 60 and older (56%), and older age was tied to worse outcomes. Overall, a fifth of patients developed severe respiratory illness, 9% required mechanical ventilation, and 12% died.

            Hospitalization was required in 40% of patients, and 20% were admitted to the ICU. Among these hospitalized and ICU patients, respectively, 24% and 35% died.

            About three-fourths of patients in the cohort had solid tumors, and breast cancer was the most common tumor type (20%), followed by lymphoma in 11%, colorectal cancer in 9%, lung cancer and leukemia in 8% each, prostate cancer in 6%, and myeloma in 5%.

            Limitations noted by the authors included the single-center design, that COVID-19-directed therapies (of which patients received a number of investigational agents) were not evaluated for this analysis, and the fact that testing at the center was only directed toward symptomatic patients.

            Here is a link to the actual data upon which this report is based: https://www.nature.com/articles/s41591-020-0979-0

            Bubbles
            Participant
              So – there you go! Sometimes whether we are the patient or the doc – we have to do the best you can. I don’t think anyone can say definitely one way or the other for several reasons. Are you a melanoma/immunotherapy patient in good health apart from taking a treatment with a risk of significant side effects and having been diagnosed with a deadly disease? Or, did you come to melanoma in a high risk group (older, over weight, smoker, etc) for COVID-19? Are you suffering from wheezing and cough due to pneumonitis caused by immunotherapy? Or are you going through immunotherapy with little difficulty? So there are those things – and then – with COVID, it is still a crap shoot. Partly because it is a disease we are very much in process of learning about. Partly because it seems to act in ways that we cannot fully anticipate, no matter the presence of risk factors or not. Perfectly healthy children and young people have died of COVID-19 while older folks with pre-existing conditions have pulled through.

              Not sure if that helps but that is as complete an answer as I can give. celeste

              Bubbles
              Participant
                And finally, since this is your thread, I will give you a response to a personal comment you made on a prior post. It may not be wise to call a person a bully one minute and ask for their help the next. Most folks who have been treated that way would give you a “big leaving alone” – as my elders called it when I was growing up. Ed has been an integral part of this board for years and I for one, am eternally grateful for his presence. He will scour the world for information for those in need and comes through when the rest of us have no answers. Real data and accurate information matters. I could give you a ton of bull shit data right now regarding your question about immunotherapy and COVID risk. What would you think of me if I did that? More importantly – what would I think of me? I would think that I did not only you – but anyone else who reads the post I put up a disservice. The reason Ed, very politely and kindly took umbrage with the prior post – as did I – is that the headline – and unfortunately what you took away from it – was misleading. The study was based on looking at 20 patients at one point in their care, via a scan, and an opinion was drawn that their immunotherapy treatment MAY have had an effect on their arthrosclerosis. There was no follow-up. There was no conclusion. There was no recommendation for treatment of arthrosclerosis for those immunotherapy patients. That is a far cry from saying – IMMUNOTHERAPY CAUSES CARDIOVASCULAR PROBLEMS – isn’t it? I think it is. We can only protect ourselves if we are armed with accurate and full disclosure of the facts. A big headline, that doesn’t tell you what was really found, does none of us any good. Ed is very good at cutting to the chase in situations like that. And we are all better for it.

                Everyone on this board has the freedom to post whatever they like. Though it is actually against the rules to call out individuals and certainly against to the rules to resort to rude accusations and petty name calling. But, most of us are adults and it ain’t no thang! And just like everyone having the right to post what they like. Everyone has the right to question it or post a rebuttal. That is not being a bully. That is having an adult discussion of some very critical important information.

                I hope you and everyone else here will post things they think are important. I also hope that when others question, doubt, agree, support, disagree, etc – ANYTHING I or ANYBODY else posts, they will state their position and back it up either with data or an experience they or someone they know has dealt with. Otherwise, what is the point?

                Yours, BOG!

                  tkoss
                  Participant
                    I appreciate the response. My onc doc and PA have had about 2 sentences of commentary on subject.

                    if you will note i did not call you a bully, just Ed.

                    Months back you questioned some stats on SR i offered up. Admittedly they were rounded off or commentary from my docs so not exactly the latest in empirical science. I explained this in a response to you and to which you didn’t reply.

                    In blogging its easy to misunderstand and get hurt feelings. By the same token your experience and knowledge gets peoples attention and you have great credibility, , so if you want to criticize me , try to be less academic and definitive in tone. and if you have a strong critique email privately. I cannot edit what has been posted buy i can correct it.

                    you will note i went on to praise you in my next post after our little dust up over SR’s.

                    i heartily lobby for an edit button if you talk to the blogsite managers.

                    Bubbles
                    Participant
                      I’m good, TKOSS. Melanoma and advocacy has given me a very thick skin. I don’t really recall any “dust up”. I am aware of who you called what. I am sorry if my academic definitive tone is not your preference. We all speak differently. We all come from different backgrounds. We all have something to offer. We all need to be tolerant of others. I feel very strongly about accuracy. Melanoma is deadly. So we desperately need facts when we can find them. Further, lots of our posts are read by folks who never ever comment. Therefore, the accuracy of what we share matters to far more people than just the writer and responder. I feel that I am in a privileged position when it comes to melanoma. I happen to have survived it for 17 years. I have seen the change in treatment options firsthand. I am medically trained. I have access to papers and literature that many do not. And hopefully, due to my training, I have the ability to explain the information I have access to in a way that makes it comprehensible to others without minimizing the data. Perhaps I am mistaken in that, but I do my best. I long to retire from this “job” and have considered doing so many times in recent years. It takes a lot of time and work to stay abreast of the data and share it here and on my blog. It is the worst paying gig, with the most criticism I have ever participated in! That’s saying something as I worked an entire summer in South Alabama cleaning bricks retrieved from a demolished building at a penny per brick. Still, I do it because I feel that I do help many people and actual real live bullies – NOT ED!!!! – have run off other dedicated intelligent responders leaving a big whole in the information provided on this forum, and whom I miss dreadfully. Thant’s all I got. I wish you my best. c
                      MelMel
                      Participant
                        Tkoss, basically you got your answer from Celeste. Stay away from me and you will get your answer answered otherwise you will be blacklisted and be blacksheep like me. I too have think skin so I could care less for I shared the current scientific studies and not quackery.
                        Melanie
                        MelMel
                        Participant
                          Celeste you agree that immunotherapy has negative impact on heart disease yet you discredit it for no reason but due to the fact that it was posted by no one other than me. How in any way is the study or the post erroneous? You have no specific data to back any of your argument up. I call that hypocritical. I have never once tried nor attempted to do anything alike neither to you nor to anyone else on this group.
                          Melanie
                          Bubbles
                          Participant
                            Melanie,

                            This is the last time I am discussing your thread. I have answered the very question you pose in multiple posts if you would but read them. We have long known that immunotherapy has had some implications for myocarditis. Proven, known, in rats, in a very few peeps. Studied. Analyzed. For years. You may look up all the data on the net, in a medical library, or find a great deal of it on my blog. This is not the same as “impact on heart disease”. Myocarditis is a condition directly caused by the therapy itself. The post you put up alluded to a sweeping risk of heart disease posed by immunotherapy in its title: “Immune-boosting cancer treatment may pose cardiovascular risk”. In reality, as Ed and I have clearly delineated, only 20 patients were examined via scan ONCE and EXISTING atherosclerosis in those patients MAY have been affected with no follow-up, no recommendation, no conclusion. In other words, what was presented in the original study/case report was very different from the tone and information (with suggestions of statins, etc.) from the “discussion” among folks admittedly NOT involved in the original data from which the article you presented was spun. My criticisms of the article are very different from a personal attack on you. This stuff is important. Folks deserve to know the whole picture as best as it can be presented by anyone.

                            In regard to your personal attacks on me: I have absolutely nothing against you as a human. I don’t believe prior to this post I have ever called your name. I certainly have never called you names! The Posting Guidelines for the forum are pretty clear. Noting: “…refrain from making comments directed at a particular individual or group…No personal attacks of any kind…” You can decide whether or not you have posted in accordance with those guidelines. However, as I noted above: “Everyone on this board has the freedom to post whatever they like. Though it is actually against the rules to call out individuals and certainly against to the rules to resort to rude accusations and petty name calling. But, most of us are adults and it ain’t no thang! And just like everyone having the right to post what they like. Everyone has the right to question it or post a rebuttal. That is not being a bully. That is having an adult discussion of some very critically important information.

                            I hope you and everyone else here will post things they think are important. I also hope that when others question, doubt, agree, support, disagree, etc – ANYTHING I or ANYBODY else posts, they will state their position and back it up either with data or an experience they or someone they know has dealt with. Otherwise, what is the point?”

                            I will continue to support the folks on this forum as best I can. I will continue to state what I think the data shows and share it with melanoma peeps here. I will share my experiences. As long as I continue my participation here, I will give a response to posts that I both differ and agree with. That is not personal. That is giving the greatest amount of information to those in need as possible.

                            Life is stressful. Melanoma turns that stress into something that is almost inconceivable unless you’ve experienced it. Been there, done that for 17 years. Even added another cancer and chemo to the equation two years ago. Given that, I have no intention of spending my remaining time on this earth fighting with anyone. Your attacks on me have been unsolicited by word or deed. I am sorry for all the anger and hostility you are dealing with. Perhaps lashing out at me and others on this board makes you feel better, though I doubt it. I hope you find peace soon. Yours, celeste

                            MelMel
                            Participant
                              Celeste, let us be completely honest. The real reason the three of you jumped at me is the fact that I believe diet and supplements hold the key in making a difference in reactions to melanoma treatment, side-effects as well as the response and healing reactions. The three of you strongly disagree. You have made that clear from day one, almost two years ago when I joined this forum. Because I continue to disagree with the three of you, then as now, you continue to discredit any and all posts not based on their scientific credibility but solely due to the fact that you see me as a thorn in your sides. I am sorry you feel that way. I am not trying to take over your forum in any way, shape or form. I just thought that the last article I posted is very pertinent since we know well there are huge side-effects, many which maybe longlasting and which may not be immediately apparent since they may show up years later. Oncologists have their hands full running the cancer clinics and may not have the time to check in detail on specifics with each patient. Cardiovascular disease involves much more than myocarditis and myocarditis was definitely not the purpose of the posted article. The article stated that 1 in 10 may end up with cardiovascular disease following immunotherapy. So how you stretch that to “sweeping” is a huge stretch of your imagination since 10% is not “sweeping” in my books, nor by any scientific standards.
                              The only thing I am sorry about is calling the three of you the name I did. Although I tried to refrain, I thought you truly deserved it. There is absolutely no need nor justification for the stretching, twisting and manipulating of information posted. It was done by credible doctors and researchers on a scientific basis as always in science. Things are true until proven scientifically otherwise. It is your perogative to disagree but not to bully. There is a huge difference.
                              If you still dislike my posts, you are free to disregard them. Obviously you do not see any value in any scientifically posted data by me.
                              If I do not have a melanoma friend, I certainly do not need any melanoma enemies. Being diagnosed with stage IV melanoma is more than enough.
                              Thank you.
                              Melanie
                              ed williams
                              Participant
                                Hi there Melanie, old geezer here and if I read your post above correctly you feel that you are being attacked for posting about diet and supplements. Ok, here is a window into my mind (scary) when I see any post on this forum or other melanoma forums that I belong to. First I read the article and second I check the background of the author if I am not familiar with them. This is what I did with your original post by Dr. Marcus Hacker. I then read his original article and it didn’t match up in several ways, here are a couple of the things that stand out. I will post his article so you can read it which will make the points I want to make, make sense I hope. https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.048708
                                ed williams
                                Participant
                                  Are you still with me so far? In Dr. Marcus Hecker’s paper about half way down first big paragraph he starts with ” This suggest that Pd-1/Pd-L1 and CTLA-4 chemokine axes” etc etc. He goes on to use references at this point ( little #;s at the end of paragraphs) since he is using the work of others to develop his theory. So, I took a look at some of these references which wasn’t hard since there were only 5 which is a flag for me at any time I read something scientific. First reference that I looked up was reference # 2 at end of paper by Esther lutgens and Tom T P Seijkens, which I will now post to let you read and see how it doesn’t agree with dr. Hecker as used in reference #2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7057415/
                                  ed williams
                                  Participant
                                    Still there, next reference (#3) is to a paper by Jeff (JA) Bluestone talking about CTLA-4 and tissue distruction, revealing a critical negative regulatory role of CTLA-4. Now we are in an area that I follow and have some background with and his name struck a cord because his work was in mice and ground breaking in the development of Ipi(yervoy) by Dr. Allison who won the noble prize in science for his work in this area. I will let Dr. Allison starting at 11:00 min mark explain this area and finishing around 15:00 min mark. He will give credit to work by Jeff Bluestone and his work in understanding of CTLA-4 in T-cell function. The key point that I am trying to make here is Dr. Marcus Hacker is using this mouse research in an article about human heart disease and it isn’t clear that he knows what his reference work (Jeff Bluestone )was actually talking about. https://www.youtube.com/watch?v=yax499WfPTg
                                    ed williams
                                    Participant
                                      Wow, Dr. Allison is great to listen to!!! The point he makes and I am trying to make is CTLA-4 if blocked by drug called Yervoy( ipi) allows T-cell to keep on trucking and killing and for some melanoma patients pretty toxic requiring steroids to get under control. Back to Dr. Marcus Hecker and his reference to Jeff Bluestone work on CTLA-4. It would make sense if you think CTLA-4 is important to cardiovascular disease as Dr. Marcus Hecker does that you would then make sure that the patients that you study have taken Ipi (yervoy) but 80% of his trial data is based on Pd-1 patients not ipi, another big red flag that this Dr. might not have the greatest knowledge of melanoma or in this case a game plan to support his hypothesis. Ok, last point is ref # 4 about using PET /ct scans from 2009 before the approval of ipi or pd-1 drugs, and this one is a kind of big, he is using his own work to justify his theory. He is using work by Marcus Hecker in 2009 not on ipi or pd-1 cancer patients. The best line is the last line of his ref # 4 which states ” larger prospective trials of patients without cancer are required to substantiate thes promising results.” http://jnm.snmjournals.org/content/50/10/1611.short
                                      ed williams
                                      Participant
                                        I know pretty scary place to visit, my mind that is and how I view research article posted on MRF!!!! It has never been about you it has always been about what you have posted , so I will finish where I started this shit show a couple of weeks ago by asking the same question as I did then , what do you mean by ” food for thought, good to be aware” Link to original post—https://melanoma.org/legacy/find-support/patient-community/mpip-melanoma-patients-information-page/immune-boosting-cancer
                                        MelMel
                                        Participant
                                          Thank you Ed but with all due respect I still stand by my original post. “Food for thought” meaning something to look at or think about or at least to be aware about. Every single pharmaceutical drug has side effects. Just from my combo immunotherapy (2 infusions) I was given steroids, celcept, sumatriptan, antacid, anti reflux med, gabapentin, Tylenol, diueritic, fluonase, and a few others just to deal with side effects from my immunotherapy. Please check the 14 pages of pharmacological information on Opdivo and 17 pages of info on Yervoy for those side effects only. So to make a long story short, please just simple logic tells you that it has huge effects on the person’s body and organs. Why are we seeing thyroid failures, pituitary failures, pancreatic issues, diabetes, frying of many glands and body wide inflammation and impact? What would make you think that the heart and cardiovascular issues are completely spared? My body is riddled with inflammation in my joints from head to toe from the immunotherapy. Who is to say that the cardiovascular system is spared? Apparently, one in ten develop cardiovascular issues following immunotherapy. This does not need to be rocket science. What the article suggests and what I physically feel with my general body inflammation and many of the melanoma patient’s personal experiences posted on this forum all suggest that inflammation and pain is real and it certainly exists. By posting my original post, I just wanted to bring attention to people to pay attention to their hearts which in the midst of things and the course of treatment may be overlooked. I see absolutely no harm in this, as I was not suggesting or recommending a pharmaceutical drug or cure but just to be aware of one of the long term possible side effects of immunotherapy which may show down the road. Nothing more, nothing less.
                                          I appreciate both Celeste’s and your own research and I am grateful to you both since I know how time consuming and dedicated you are.
                                          Melanie
                                        ed williams
                                        Participant
                                          Hi tKoss, old geezer with links for you. First one features Dr. Long from Australia, second link is written by some of the top names in the melanoma business on the topic you are interested in and last link is to new published ranking of melanoma experts based on publishing history which is kind of different and new. https://www.youtube.com/watch?v=U4w__yYA_wk&feature=youtu.be https://clincancerres.aacrjournals.org/content/26/16/4201 https://expertscape.com/ex/melanoma
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