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Need Direction…latest & greatest

Forums General Melanoma Community Need Direction…latest & greatest

  • Post
    JoshF
    Participant

      Hi guys! I'm always hoping to post something good and I'm just not getting good news. So brain MRI results showed 3 new leisons. All of them are small. Biggest is just under a CM. My LDH is now up yo 1770 and platelets at 513. So TIL is postponed so I can get gamma knife Tuesday. I'm still going to MDA on Wednesday for CT Scan and another biopsy. Anybody want to show up and punch me in the face? I'm getting scared here guys & gals. I'm more scared of possibly having to have " the talk" with my 13yo son and 10yo daughter. I can take this crap but those thoughts of them…. Which is why I'm asking for any & all suggestions. I want to be more than prepared next week when I see doctor at MDA. Celeste's blog is great and she put a ton of info on there in past for me. That was 7 months ago so anything new, exciting or showing promise would be great. I've been scouring clinical trial site but that lacks insight many of you fine people have. I've got fight in me left but these trials can have road blocks. I'm at a loss right now. 

      Josh

    Viewing 74 reply threads
    • Replies
        jennunicorn
        Participant

          I wish I had some advice for you Josh, but I at least want to send out a huge hug. 

          Hoping this roller coaster stops giving you these awful twists and starts to become a more positive ride.

          Keep that fight alive.

          jennunicorn
          Participant

            I wish I had some advice for you Josh, but I at least want to send out a huge hug. 

            Hoping this roller coaster stops giving you these awful twists and starts to become a more positive ride.

            Keep that fight alive.

            jennunicorn
            Participant

              I wish I had some advice for you Josh, but I at least want to send out a huge hug. 

              Hoping this roller coaster stops giving you these awful twists and starts to become a more positive ride.

              Keep that fight alive.

              _Paul_
              Participant

                Crao Josh, I don't (yet) have experience with brain mets, but I do know that if you have a choice between cyberknife and gamma knife, the cyberknife does not require a rigid head frame to be screwed against your head. I don't know about the effectiveness of one over the other – I think they are both excellent but maybe someone with experience can chime in.

                _Paul_
                Participant

                  Crao Josh, I don't (yet) have experience with brain mets, but I do know that if you have a choice between cyberknife and gamma knife, the cyberknife does not require a rigid head frame to be screwed against your head. I don't know about the effectiveness of one over the other – I think they are both excellent but maybe someone with experience can chime in.

                  _Paul_
                  Participant

                    Crao Josh, I don't (yet) have experience with brain mets, but I do know that if you have a choice between cyberknife and gamma knife, the cyberknife does not require a rigid head frame to be screwed against your head. I don't know about the effectiveness of one over the other – I think they are both excellent but maybe someone with experience can chime in.

                    Patina
                    Participant
                      Ask about getting ipi or keytruda within days of gamma knife. My Mom had the abscopal affect. She started ipi 4 days after gamma knife.

                      Keytruda may work faster on the brain and people who responded to ipi seen to respond as well ot better, if this helps. – Per my Mom’s doctors.

                      I always recommend a second opinion. So find the best guy or gal (really team) and act fast.

                      I have recently heard that they can do stereotactic body radiation therapy (SBRT). It kinda works like gamma knife for soft tissue tumors. It might be worth checking into this for other masses.

                      You will be in my thoughts. You can kick this.

                      PS
                      Be sure your doctor’s put you on keppra at 1000mg. Stay on it for 6 months. You have a high chance of seizures and you don’t want to be sidelined because you had one. My Mom took it at night. – 500mg 2x a day made her a zombie.

                      Patina
                      Participant
                        Ask about getting ipi or keytruda within days of gamma knife. My Mom had the abscopal affect. She started ipi 4 days after gamma knife.

                        Keytruda may work faster on the brain and people who responded to ipi seen to respond as well ot better, if this helps. – Per my Mom’s doctors.

                        I always recommend a second opinion. So find the best guy or gal (really team) and act fast.

                        I have recently heard that they can do stereotactic body radiation therapy (SBRT). It kinda works like gamma knife for soft tissue tumors. It might be worth checking into this for other masses.

                        You will be in my thoughts. You can kick this.

                        PS
                        Be sure your doctor’s put you on keppra at 1000mg. Stay on it for 6 months. You have a high chance of seizures and you don’t want to be sidelined because you had one. My Mom took it at night. – 500mg 2x a day made her a zombie.

                        Patina
                        Participant
                          Ask about getting ipi or keytruda within days of gamma knife. My Mom had the abscopal affect. She started ipi 4 days after gamma knife.

                          Keytruda may work faster on the brain and people who responded to ipi seen to respond as well ot better, if this helps. – Per my Mom’s doctors.

                          I always recommend a second opinion. So find the best guy or gal (really team) and act fast.

                          I have recently heard that they can do stereotactic body radiation therapy (SBRT). It kinda works like gamma knife for soft tissue tumors. It might be worth checking into this for other masses.

                          You will be in my thoughts. You can kick this.

                          PS
                          Be sure your doctor’s put you on keppra at 1000mg. Stay on it for 6 months. You have a high chance of seizures and you don’t want to be sidelined because you had one. My Mom took it at night. – 500mg 2x a day made her a zombie.

                          Mat
                          Participant

                            Josh, sorry to hear.  When my TIL cells didn't grow at MDA last year, I moved to ipi/nivo (after having failed ipi and Keytruda individually). Results have been good so far.  Not sure if this is an option given the close proximity to ipi, but maybe you could aim for 2 combined infusions before moving to nivo only?

                              BrianP
                              Participant

                                I like the ipi/nivo option also not only for the efficacy possibilities but also for the timeliness.  I would think you could get an infusion within a couple weeks.  I'll be at MDA next week but only for support if needed, not punches.

                                Brian

                                BrianP
                                Participant

                                  Josh,

                                  You might want to ask MDA about the NCI Match trial.  I don't know a whole lot about it but my oncologist at Duke mentioned it to me for something to consider down the road.  The trial takes a sample of your tumor and does an extensive genetics analysis and then prescribes a drug based on the genetics.  It might be a breast cancer drug it could be a corectal cancer drug it all depends on what the analysis determines would be the best treatment for your cancer's genetics.  Here's a link to the trial.

                                  https://clinicaltrials.gov/ct2/show/NCT02465060?term=nci+match&rank=1

                                  They are doing it at 100's of locations. 

                                  Brian

                                  BrianP
                                  Participant

                                    Josh,

                                    You might want to ask MDA about the NCI Match trial.  I don't know a whole lot about it but my oncologist at Duke mentioned it to me for something to consider down the road.  The trial takes a sample of your tumor and does an extensive genetics analysis and then prescribes a drug based on the genetics.  It might be a breast cancer drug it could be a corectal cancer drug it all depends on what the analysis determines would be the best treatment for your cancer's genetics.  Here's a link to the trial.

                                    https://clinicaltrials.gov/ct2/show/NCT02465060?term=nci+match&rank=1

                                    They are doing it at 100's of locations. 

                                    Brian

                                    BrianP
                                    Participant

                                      Josh,

                                      You might want to ask MDA about the NCI Match trial.  I don't know a whole lot about it but my oncologist at Duke mentioned it to me for something to consider down the road.  The trial takes a sample of your tumor and does an extensive genetics analysis and then prescribes a drug based on the genetics.  It might be a breast cancer drug it could be a corectal cancer drug it all depends on what the analysis determines would be the best treatment for your cancer's genetics.  Here's a link to the trial.

                                      https://clinicaltrials.gov/ct2/show/NCT02465060?term=nci+match&rank=1

                                      They are doing it at 100's of locations. 

                                      Brian

                                      BrianP
                                      Participant

                                        I like the ipi/nivo option also not only for the efficacy possibilities but also for the timeliness.  I would think you could get an infusion within a couple weeks.  I'll be at MDA next week but only for support if needed, not punches.

                                        Brian

                                        BrianP
                                        Participant

                                          I like the ipi/nivo option also not only for the efficacy possibilities but also for the timeliness.  I would think you could get an infusion within a couple weeks.  I'll be at MDA next week but only for support if needed, not punches.

                                          Brian

                                        Mat
                                        Participant

                                          Josh, sorry to hear.  When my TIL cells didn't grow at MDA last year, I moved to ipi/nivo (after having failed ipi and Keytruda individually). Results have been good so far.  Not sure if this is an option given the close proximity to ipi, but maybe you could aim for 2 combined infusions before moving to nivo only?

                                          Mat
                                          Participant

                                            Josh, sorry to hear.  When my TIL cells didn't grow at MDA last year, I moved to ipi/nivo (after having failed ipi and Keytruda individually). Results have been good so far.  Not sure if this is an option given the close proximity to ipi, but maybe you could aim for 2 combined infusions before moving to nivo only?

                                            momof4boys
                                            Participant
                                              I just wanted to say you have a lot of people rooting for you here. Try to take it one day at a time.
                                                Mark_DC
                                                Participant

                                                  Am one of the many on this board rooting for you. Hope the ideas and advice others who are much nore qualified are giving will work. You are a great resource and source of support for us, thank you

                                                  Mark_DC
                                                  Participant

                                                    Am one of the many on this board rooting for you. Hope the ideas and advice others who are much nore qualified are giving will work. You are a great resource and source of support for us, thank you

                                                    Mark_DC
                                                    Participant

                                                      Am one of the many on this board rooting for you. Hope the ideas and advice others who are much nore qualified are giving will work. You are a great resource and source of support for us, thank you

                                                    momof4boys
                                                    Participant
                                                      I just wanted to say you have a lot of people rooting for you here. Try to take it one day at a time.
                                                      momof4boys
                                                      Participant
                                                        I just wanted to say you have a lot of people rooting for you here. Try to take it one day at a time.
                                                        ed williams
                                                        Participant

                                                          Hi Josh, just to add to the ideas that already have been given to you is a new combination that was posted on the forum earlier this week, which combines Pembro with SD-101 a TLR9 agonist drug from a company called Dynavax technologies. Here is a link to the company, and I believe they are doing some trials with this at Stanford. http://www.marketwired.com/press-release/dynavax-presents-early-clinical-data-from-lead-cancer-immunotherapy-candidate-sd-101-nasdaq-dvax-2165023.htm   On using cyberknife or gamma knife , while I don't have any data but I do have personal experience with cyberknife and it was super easy system. They fitted me for a mask that attached to the table and the treatment lasted about 50min to treat 3 tumors ranging in size from 4 to 5mm. That was back in the fall of 2013 and I have been lucky to have no side effects so far. Best Wishes!!! Ed

                                                            ed williams
                                                            Participant

                                                              I gave you the wrong link above sorry!!! Edhttp://www.dynavax.com/our-pipeline/cancer-immunotherapy/sd101/

                                                              ed williams
                                                              Participant

                                                                I gave you the wrong link above sorry!!! Edhttp://www.dynavax.com/our-pipeline/cancer-immunotherapy/sd101/

                                                                ed williams
                                                                Participant

                                                                  I gave you the wrong link above sorry!!! Edhttp://www.dynavax.com/our-pipeline/cancer-immunotherapy/sd101/

                                                                ed williams
                                                                Participant

                                                                  Hi Josh, just to add to the ideas that already have been given to you is a new combination that was posted on the forum earlier this week, which combines Pembro with SD-101 a TLR9 agonist drug from a company called Dynavax technologies. Here is a link to the company, and I believe they are doing some trials with this at Stanford. http://www.marketwired.com/press-release/dynavax-presents-early-clinical-data-from-lead-cancer-immunotherapy-candidate-sd-101-nasdaq-dvax-2165023.htm   On using cyberknife or gamma knife , while I don't have any data but I do have personal experience with cyberknife and it was super easy system. They fitted me for a mask that attached to the table and the treatment lasted about 50min to treat 3 tumors ranging in size from 4 to 5mm. That was back in the fall of 2013 and I have been lucky to have no side effects so far. Best Wishes!!! Ed

                                                                  ed williams
                                                                  Participant

                                                                    Hi Josh, just to add to the ideas that already have been given to you is a new combination that was posted on the forum earlier this week, which combines Pembro with SD-101 a TLR9 agonist drug from a company called Dynavax technologies. Here is a link to the company, and I believe they are doing some trials with this at Stanford. http://www.marketwired.com/press-release/dynavax-presents-early-clinical-data-from-lead-cancer-immunotherapy-candidate-sd-101-nasdaq-dvax-2165023.htm   On using cyberknife or gamma knife , while I don't have any data but I do have personal experience with cyberknife and it was super easy system. They fitted me for a mask that attached to the table and the treatment lasted about 50min to treat 3 tumors ranging in size from 4 to 5mm. That was back in the fall of 2013 and I have been lucky to have no side effects so far. Best Wishes!!! Ed

                                                                    Bubbles
                                                                    Participant

                                                                      Oh Joshie!  Shit!  So very sorry. I am thinking.  First thing out of the box:  I know some folks who failed to respond to much of anything and are currently doing well on a combo of  anti-PD1 and urelumab.  There are still all the intralesionals….which are looking good combined with anti-PD1.  There's atezolizumab…alone or with other products.  Here is a link in which Weber talks about lots of upcoming therapies….with things he thinks will be tested and have promise at the bottom. 

                                                                      http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2016/03/immunology-updatewebinar-for-melanoma.html

                                                                      Obviously, I have not researched where all these are offered or what obstacles may be present for your participation, but I will keep thinking.  May post on blog since too many links here are blocked. 

                                                                      But….radiation to brain mets…SRS or otherwise, sounds like a good first order of business.  The ipi/nivo combo doesn't sound too bad….perhaps it will give success (maybe!!) or at least keep things stable until you decide what to do next. 

                                                                      Hang in there sweetie.  love, c

                                                                      Bubbles
                                                                      Participant

                                                                        Oh Joshie!  Shit!  So very sorry. I am thinking.  First thing out of the box:  I know some folks who failed to respond to much of anything and are currently doing well on a combo of  anti-PD1 and urelumab.  There are still all the intralesionals….which are looking good combined with anti-PD1.  There's atezolizumab…alone or with other products.  Here is a link in which Weber talks about lots of upcoming therapies….with things he thinks will be tested and have promise at the bottom. 

                                                                        http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2016/03/immunology-updatewebinar-for-melanoma.html

                                                                        Obviously, I have not researched where all these are offered or what obstacles may be present for your participation, but I will keep thinking.  May post on blog since too many links here are blocked. 

                                                                        But….radiation to brain mets…SRS or otherwise, sounds like a good first order of business.  The ipi/nivo combo doesn't sound too bad….perhaps it will give success (maybe!!) or at least keep things stable until you decide what to do next. 

                                                                        Hang in there sweetie.  love, c

                                                                        Bubbles
                                                                        Participant

                                                                          Oh Joshie!  Shit!  So very sorry. I am thinking.  First thing out of the box:  I know some folks who failed to respond to much of anything and are currently doing well on a combo of  anti-PD1 and urelumab.  There are still all the intralesionals….which are looking good combined with anti-PD1.  There's atezolizumab…alone or with other products.  Here is a link in which Weber talks about lots of upcoming therapies….with things he thinks will be tested and have promise at the bottom. 

                                                                          http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2016/03/immunology-updatewebinar-for-melanoma.html

                                                                          Obviously, I have not researched where all these are offered or what obstacles may be present for your participation, but I will keep thinking.  May post on blog since too many links here are blocked. 

                                                                          But….radiation to brain mets…SRS or otherwise, sounds like a good first order of business.  The ipi/nivo combo doesn't sound too bad….perhaps it will give success (maybe!!) or at least keep things stable until you decide what to do next. 

                                                                          Hang in there sweetie.  love, c

                                                                          gregor913
                                                                          Participant
                                                                            Josh you were one of the first people to respond to me and ill always will remember that. But remember your strong and you said you feel strong. Keep that in mind. My sisters friends dad has been stage 4 for 17 years. Hes had his ups and downs. But is still here. I get emotional and go to that place. My sister tells me not to go to that place until the doctors have told you there is nothing for them to do. You on the other hand have options. Each day in the medical field they learn more. I was reading a article that a dr at a hospital has made a nano fiber that is smaller then a piece of hair. Where when heated up it destroys the tumor. Melanoma was one of the cancers they said they wanted to use it for along with stomach. Greg
                                                                            gregor913
                                                                            Participant
                                                                              Josh you were one of the first people to respond to me and ill always will remember that. But remember your strong and you said you feel strong. Keep that in mind. My sisters friends dad has been stage 4 for 17 years. Hes had his ups and downs. But is still here. I get emotional and go to that place. My sister tells me not to go to that place until the doctors have told you there is nothing for them to do. You on the other hand have options. Each day in the medical field they learn more. I was reading a article that a dr at a hospital has made a nano fiber that is smaller then a piece of hair. Where when heated up it destroys the tumor. Melanoma was one of the cancers they said they wanted to use it for along with stomach. Greg
                                                                              gregor913
                                                                              Participant
                                                                                Josh you were one of the first people to respond to me and ill always will remember that. But remember your strong and you said you feel strong. Keep that in mind. My sisters friends dad has been stage 4 for 17 years. Hes had his ups and downs. But is still here. I get emotional and go to that place. My sister tells me not to go to that place until the doctors have told you there is nothing for them to do. You on the other hand have options. Each day in the medical field they learn more. I was reading a article that a dr at a hospital has made a nano fiber that is smaller then a piece of hair. Where when heated up it destroys the tumor. Melanoma was one of the cancers they said they wanted to use it for along with stomach. Greg
                                                                                debwray
                                                                                Participant

                                                                                  Hi Josh,

                                                                                  Think you have already had more than enough punches.. like many of us here. 

                                                                                  I can empathise with your fear of "the talk " wih your children ..as this was a cause of much distress to me when I got the stage IV diagnosis. My daughter had already sensed that things weren't going well , and so in a wayI think it was a relief to her when we spelt out the situation .. in as far as we could. Uncertainty  as to the future is a constant companion but the TIL trial may be the thing that changes your luck and we all need some on this journey. In a way it was a relief when both my son and daughter knew how serious the melanoma was  , and we have cried together and hugged each other for comfort. 

                                                                                  Your children are much younger than mine, but you may be surprised at how much they already know or understand implicitly.  I guess it all depends on how much you have told them so far. My oncologist told me its not over yet and the same applies to you. The gamma knife may even help the TIL therapy work.. but that is something you probably know already… but there are heaps of folk willing it to be the case for you and maybe that will make the difference.

                                                                                  Keep on keeping on and  fighting for a cure,

                                                                                  Best of wishes to you and the family

                                                                                  Deb

                                                                                   

                                                                                   

                                                                                   

                                                                                  debwray
                                                                                  Participant

                                                                                    Hi Josh,

                                                                                    Think you have already had more than enough punches.. like many of us here. 

                                                                                    I can empathise with your fear of "the talk " wih your children ..as this was a cause of much distress to me when I got the stage IV diagnosis. My daughter had already sensed that things weren't going well , and so in a wayI think it was a relief to her when we spelt out the situation .. in as far as we could. Uncertainty  as to the future is a constant companion but the TIL trial may be the thing that changes your luck and we all need some on this journey. In a way it was a relief when both my son and daughter knew how serious the melanoma was  , and we have cried together and hugged each other for comfort. 

                                                                                    Your children are much younger than mine, but you may be surprised at how much they already know or understand implicitly.  I guess it all depends on how much you have told them so far. My oncologist told me its not over yet and the same applies to you. The gamma knife may even help the TIL therapy work.. but that is something you probably know already… but there are heaps of folk willing it to be the case for you and maybe that will make the difference.

                                                                                    Keep on keeping on and  fighting for a cure,

                                                                                    Best of wishes to you and the family

                                                                                    Deb

                                                                                     

                                                                                     

                                                                                     

                                                                                    debwray
                                                                                    Participant

                                                                                      Hi Josh,

                                                                                      Think you have already had more than enough punches.. like many of us here. 

                                                                                      I can empathise with your fear of "the talk " wih your children ..as this was a cause of much distress to me when I got the stage IV diagnosis. My daughter had already sensed that things weren't going well , and so in a wayI think it was a relief to her when we spelt out the situation .. in as far as we could. Uncertainty  as to the future is a constant companion but the TIL trial may be the thing that changes your luck and we all need some on this journey. In a way it was a relief when both my son and daughter knew how serious the melanoma was  , and we have cried together and hugged each other for comfort. 

                                                                                      Your children are much younger than mine, but you may be surprised at how much they already know or understand implicitly.  I guess it all depends on how much you have told them so far. My oncologist told me its not over yet and the same applies to you. The gamma knife may even help the TIL therapy work.. but that is something you probably know already… but there are heaps of folk willing it to be the case for you and maybe that will make the difference.

                                                                                      Keep on keeping on and  fighting for a cure,

                                                                                      Best of wishes to you and the family

                                                                                      Deb

                                                                                       

                                                                                       

                                                                                       

                                                                                      SABKLYN
                                                                                      Participant

                                                                                        Hey Josh,

                                                                                        Certainly not the news you were looking for, but as other respondents have said, you ARE NOT out of options.  I can't speak intelligibly about the different therapies, but there appear to be several.  You're at one of the best places to fight this, but maybe investigating other opinions would be beneficial.  Perhaps a call to Dana Farber or Memorial Sloan Kettering might yield different paths or treatment modalities.  

                                                                                        I really just wanted to show my support for you just as you've always shown support for others.

                                                                                        All the best and keep us posted, brother.

                                                                                         

                                                                                        Stan

                                                                                        SABKLYN
                                                                                        Participant

                                                                                          Hey Josh,

                                                                                          Certainly not the news you were looking for, but as other respondents have said, you ARE NOT out of options.  I can't speak intelligibly about the different therapies, but there appear to be several.  You're at one of the best places to fight this, but maybe investigating other opinions would be beneficial.  Perhaps a call to Dana Farber or Memorial Sloan Kettering might yield different paths or treatment modalities.  

                                                                                          I really just wanted to show my support for you just as you've always shown support for others.

                                                                                          All the best and keep us posted, brother.

                                                                                           

                                                                                          Stan

                                                                                          SABKLYN
                                                                                          Participant

                                                                                            Hey Josh,

                                                                                            Certainly not the news you were looking for, but as other respondents have said, you ARE NOT out of options.  I can't speak intelligibly about the different therapies, but there appear to be several.  You're at one of the best places to fight this, but maybe investigating other opinions would be beneficial.  Perhaps a call to Dana Farber or Memorial Sloan Kettering might yield different paths or treatment modalities.  

                                                                                            I really just wanted to show my support for you just as you've always shown support for others.

                                                                                            All the best and keep us posted, brother.

                                                                                             

                                                                                            Stan

                                                                                            Polymath
                                                                                            Participant

                                                                                              Hey Josh,

                                                                                              We understand you are battle fatigued.  This road is so full of potholes, it often seems we can never get our footing back.  You are one tough cookie, and have much to live for so back into the trenches you must go.  Regarding the conversation with kids, I often wonder how or when I'll need to have that talk but am keeping it all to myself because there is no upside for them.  It will happen only if it needs to happen. Although I have chosen surgery to get a reset on my disease, I was really debating one more go-round of drug therapy with what seems like a really promising trial of Durvalumab combined with Epacadostat.  Especially of interest is the IDO inhibitor, which like CTLA-4 and PD-1, is newly discovered checkpoint inhibitor.  As I recall you also never went the anti PD-1 route and as noted in other messages here, it seems like a natural.  There may even be trials combining the anti PD-1 and IDO which sounds like a kick-ass combo.  In any event, the main thing is as tough as things are right now, it definitely is not over and options remain.  You are in the thoughts and prayers of many here.  The positive energy is surrounding you.  Stay strong my friend, keep fighting the good fight, and seek peace within.

                                                                                              Gary

                                                                                                JoshF
                                                                                                Participant

                                                                                                  Gary-

                                                                                                  appreciate the support! My fear is having to talk to my kids if things go real bad. They're aware of what's going on but I don't think they understand the gravity. My son may but at this point he just thinks his dad will prevail. It's just horrible to think that they'd have to deal with this more than they have. We hate hurting or seeing the people around us suffer because of this disease and its out of our control. 

                                                                                                  I did do Nivo and that's when disease went crazy, like the PD-1 pissed it off. So unfortunately in some trials where they'd allow ipi but not PD-1, I don't qualify. There are options though and combo is way to go. I'll get this gamma knife Tuesday and head to Houston Wednesday to see what they have to say. Appreciate everything!

                                                                                                  Josh

                                                                                                  JoshF
                                                                                                  Participant

                                                                                                    Gary-

                                                                                                    appreciate the support! My fear is having to talk to my kids if things go real bad. They're aware of what's going on but I don't think they understand the gravity. My son may but at this point he just thinks his dad will prevail. It's just horrible to think that they'd have to deal with this more than they have. We hate hurting or seeing the people around us suffer because of this disease and its out of our control. 

                                                                                                    I did do Nivo and that's when disease went crazy, like the PD-1 pissed it off. So unfortunately in some trials where they'd allow ipi but not PD-1, I don't qualify. There are options though and combo is way to go. I'll get this gamma knife Tuesday and head to Houston Wednesday to see what they have to say. Appreciate everything!

                                                                                                    Josh

                                                                                                    JoshF
                                                                                                    Participant

                                                                                                      Gary-

                                                                                                      appreciate the support! My fear is having to talk to my kids if things go real bad. They're aware of what's going on but I don't think they understand the gravity. My son may but at this point he just thinks his dad will prevail. It's just horrible to think that they'd have to deal with this more than they have. We hate hurting or seeing the people around us suffer because of this disease and its out of our control. 

                                                                                                      I did do Nivo and that's when disease went crazy, like the PD-1 pissed it off. So unfortunately in some trials where they'd allow ipi but not PD-1, I don't qualify. There are options though and combo is way to go. I'll get this gamma knife Tuesday and head to Houston Wednesday to see what they have to say. Appreciate everything!

                                                                                                      Josh

                                                                                                    Polymath
                                                                                                    Participant

                                                                                                      Hey Josh,

                                                                                                      We understand you are battle fatigued.  This road is so full of potholes, it often seems we can never get our footing back.  You are one tough cookie, and have much to live for so back into the trenches you must go.  Regarding the conversation with kids, I often wonder how or when I'll need to have that talk but am keeping it all to myself because there is no upside for them.  It will happen only if it needs to happen. Although I have chosen surgery to get a reset on my disease, I was really debating one more go-round of drug therapy with what seems like a really promising trial of Durvalumab combined with Epacadostat.  Especially of interest is the IDO inhibitor, which like CTLA-4 and PD-1, is newly discovered checkpoint inhibitor.  As I recall you also never went the anti PD-1 route and as noted in other messages here, it seems like a natural.  There may even be trials combining the anti PD-1 and IDO which sounds like a kick-ass combo.  In any event, the main thing is as tough as things are right now, it definitely is not over and options remain.  You are in the thoughts and prayers of many here.  The positive energy is surrounding you.  Stay strong my friend, keep fighting the good fight, and seek peace within.

                                                                                                      Gary

                                                                                                      Polymath
                                                                                                      Participant

                                                                                                        Hey Josh,

                                                                                                        We understand you are battle fatigued.  This road is so full of potholes, it often seems we can never get our footing back.  You are one tough cookie, and have much to live for so back into the trenches you must go.  Regarding the conversation with kids, I often wonder how or when I'll need to have that talk but am keeping it all to myself because there is no upside for them.  It will happen only if it needs to happen. Although I have chosen surgery to get a reset on my disease, I was really debating one more go-round of drug therapy with what seems like a really promising trial of Durvalumab combined with Epacadostat.  Especially of interest is the IDO inhibitor, which like CTLA-4 and PD-1, is newly discovered checkpoint inhibitor.  As I recall you also never went the anti PD-1 route and as noted in other messages here, it seems like a natural.  There may even be trials combining the anti PD-1 and IDO which sounds like a kick-ass combo.  In any event, the main thing is as tough as things are right now, it definitely is not over and options remain.  You are in the thoughts and prayers of many here.  The positive energy is surrounding you.  Stay strong my friend, keep fighting the good fight, and seek peace within.

                                                                                                        Gary

                                                                                                        Bubbles
                                                                                                        Participant

                                                                                                          SD-101 (dynavex) with pembro:  https://clinicaltrials.gov/ct2/show/NCT02521870?term=SD+-+101+and+pembrolizumab&rank=1

                                                                                                          This is what Ed was sharing above.  Got this tip from my dear Eric who is looking hard for you, too, Joshie.  Some arms do have an exclusion for prior immunotherapy…but it looks as though some allow it.  c

                                                                                                          Bubbles
                                                                                                          Participant

                                                                                                            SD-101 (dynavex) with pembro:  https://clinicaltrials.gov/ct2/show/NCT02521870?term=SD+-+101+and+pembrolizumab&rank=1

                                                                                                            This is what Ed was sharing above.  Got this tip from my dear Eric who is looking hard for you, too, Joshie.  Some arms do have an exclusion for prior immunotherapy…but it looks as though some allow it.  c

                                                                                                            Bubbles
                                                                                                            Participant

                                                                                                              SD-101 (dynavex) with pembro:  https://clinicaltrials.gov/ct2/show/NCT02521870?term=SD+-+101+and+pembrolizumab&rank=1

                                                                                                              This is what Ed was sharing above.  Got this tip from my dear Eric who is looking hard for you, too, Joshie.  Some arms do have an exclusion for prior immunotherapy…but it looks as though some allow it.  c

                                                                                                              Bubbles
                                                                                                              Participant

                                                                                                                And this IS RECRUITING!!!  Enoblitzumab (NGA271) with Pembro:  https://clinicaltrials.gov/ct2/show/NCT02475213?term=melanoma+271&rank=3

                                                                                                                You may have to have brain tumors zapped before and be off any steriods for a couple of weeks…but there doesn't seem to be any other exclusion that would affect you.  However, you do have to be positive for B7H3, as surface antigen, that they will test your tumor for.

                                                                                                                Kinda like this one!!  c

                                                                                                                Bubbles
                                                                                                                Participant

                                                                                                                  And this IS RECRUITING!!!  Enoblitzumab (NGA271) with Pembro:  https://clinicaltrials.gov/ct2/show/NCT02475213?term=melanoma+271&rank=3

                                                                                                                  You may have to have brain tumors zapped before and be off any steriods for a couple of weeks…but there doesn't seem to be any other exclusion that would affect you.  However, you do have to be positive for B7H3, as surface antigen, that they will test your tumor for.

                                                                                                                  Kinda like this one!!  c

                                                                                                                  Bubbles
                                                                                                                  Participant

                                                                                                                    And this IS RECRUITING!!!  Enoblitzumab (NGA271) with Pembro:  https://clinicaltrials.gov/ct2/show/NCT02475213?term=melanoma+271&rank=3

                                                                                                                    You may have to have brain tumors zapped before and be off any steriods for a couple of weeks…but there doesn't seem to be any other exclusion that would affect you.  However, you do have to be positive for B7H3, as surface antigen, that they will test your tumor for.

                                                                                                                    Kinda like this one!!  c

                                                                                                                    Bubbles
                                                                                                                    Participant

                                                                                                                      This is recruiting in lots of locations.  It is NGA271 (enoblitzumab) alone.  There seem to be NO problematic exclusions.  Still nee to be positive for B7H3.  https://clinicaltrials.gov/ct2/show/NCT01391143?term=melanoma+271&rank=4

                                                                                                                      Bubbles
                                                                                                                      Participant

                                                                                                                        This is recruiting in lots of locations.  It is NGA271 (enoblitzumab) alone.  There seem to be NO problematic exclusions.  Still nee to be positive for B7H3.  https://clinicaltrials.gov/ct2/show/NCT01391143?term=melanoma+271&rank=4

                                                                                                                        Bubbles
                                                                                                                        Participant

                                                                                                                          This is recruiting in lots of locations.  It is NGA271 (enoblitzumab) alone.  There seem to be NO problematic exclusions.  Still nee to be positive for B7H3.  https://clinicaltrials.gov/ct2/show/NCT01391143?term=melanoma+271&rank=4

                                                                                                                          Bubbles
                                                                                                                          Participant

                                                                                                                            Here is another that is recruiting:  Epacadostat with vaccine:  https://clinicaltrials.gov/ct2/show/NCT01961115?term=epacadostat+and+melanoma&rank=2

                                                                                                                            No exclusions seem problematic.  c

                                                                                                                              JoshF
                                                                                                                              Participant

                                                                                                                                Thank you for all you've done for me. The digging around and trying to find options. This may be a good one but I think my LDH may be too high. It said 5x the upper limit. Mine is like 7x right now. I'd have to see what values they use.

                                                                                                                                love 

                                                                                                                                Joshie

                                                                                                                                JoshF
                                                                                                                                Participant

                                                                                                                                  Thank you for all you've done for me. The digging around and trying to find options. This may be a good one but I think my LDH may be too high. It said 5x the upper limit. Mine is like 7x right now. I'd have to see what values they use.

                                                                                                                                  love 

                                                                                                                                  Joshie

                                                                                                                                  JoshF
                                                                                                                                  Participant

                                                                                                                                    Thank you for all you've done for me. The digging around and trying to find options. This may be a good one but I think my LDH may be too high. It said 5x the upper limit. Mine is like 7x right now. I'd have to see what values they use.

                                                                                                                                    love 

                                                                                                                                    Joshie

                                                                                                                                  Bubbles
                                                                                                                                  Participant

                                                                                                                                    Here is another that is recruiting:  Epacadostat with vaccine:  https://clinicaltrials.gov/ct2/show/NCT01961115?term=epacadostat+and+melanoma&rank=2

                                                                                                                                    No exclusions seem problematic.  c

                                                                                                                                    Bubbles
                                                                                                                                    Participant

                                                                                                                                      Here is another that is recruiting:  Epacadostat with vaccine:  https://clinicaltrials.gov/ct2/show/NCT01961115?term=epacadostat+and+melanoma&rank=2

                                                                                                                                      No exclusions seem problematic.  c

                                                                                                                                      RayPMcConnell
                                                                                                                                      Participant

                                                                                                                                        I'm praying for you and your family, Josh.

                                                                                                                                         

                                                                                                                                        RayPMcConnell
                                                                                                                                        Participant

                                                                                                                                          I'm praying for you and your family, Josh.

                                                                                                                                           

                                                                                                                                          RayPMcConnell
                                                                                                                                          Participant

                                                                                                                                            I'm praying for you and your family, Josh.

                                                                                                                                             

                                                                                                                                            Casitas1
                                                                                                                                            Participant
                                                                                                                                              Hey Josh, Keep your duke’s up! You’ve had some bad body blows. You have the best Drs. Family and all of us in your corner. You will win this Bout!!!

                                                                                                                                              Best,Paul

                                                                                                                                              Casitas1
                                                                                                                                              Participant
                                                                                                                                                Hey Josh, Keep your duke’s up! You’ve had some bad body blows. You have the best Drs. Family and all of us in your corner. You will win this Bout!!!

                                                                                                                                                Best,Paul

                                                                                                                                                Casitas1
                                                                                                                                                Participant
                                                                                                                                                  Hey Josh, Keep your duke’s up! You’ve had some bad body blows. You have the best Drs. Family and all of us in your corner. You will win this Bout!!!

                                                                                                                                                  Best,Paul

                                                                                                                                                  JoshF
                                                                                                                                                  Participant

                                                                                                                                                    Thank you to all for you kindness, love & support. You're truly amazing people. I was overwhelmed just reading all of these and whether you're a well wisher, giving advice/trial info or both, it means the world to me. Knowing there's a community out there who is living and knows what this is like is comforting and inspirational. There's days I'm not sure I'm going to make it. So we push on in this battle. I love you all and I'm grateful you're part of my army!

                                                                                                                                                    Josh

                                                                                                                                                    JoshF
                                                                                                                                                    Participant

                                                                                                                                                      Thank you to all for you kindness, love & support. You're truly amazing people. I was overwhelmed just reading all of these and whether you're a well wisher, giving advice/trial info or both, it means the world to me. Knowing there's a community out there who is living and knows what this is like is comforting and inspirational. There's days I'm not sure I'm going to make it. So we push on in this battle. I love you all and I'm grateful you're part of my army!

                                                                                                                                                      Josh

                                                                                                                                                      JoshF
                                                                                                                                                      Participant

                                                                                                                                                        Thank you to all for you kindness, love & support. You're truly amazing people. I was overwhelmed just reading all of these and whether you're a well wisher, giving advice/trial info or both, it means the world to me. Knowing there's a community out there who is living and knows what this is like is comforting and inspirational. There's days I'm not sure I'm going to make it. So we push on in this battle. I love you all and I'm grateful you're part of my army!

                                                                                                                                                        Josh

                                                                                                                                                        AshleyS
                                                                                                                                                        Participant

                                                                                                                                                          Hey Josh,

                                                                                                                                                          I'm not a huge help but the advice you've received is great. It's so tough knowing what step to take. Although my kiddos are too young for "the talk," I remember all the thoughts I had when my health was bad. I often talked to God (in my head) and felt that I wasn't afraid to die, but I was afraid of what my family would go through if I did. 

                                                                                                                                                          My husband and I are in Houston right now through Monday. If you're still around and need anything – coffee delivered, a movie night, or two sets of ears to listen, please don't hesitate to reach out. 

                                                                                                                                                          Ashley

                                                                                                                                                          701-721-6177

                                                                                                                                                          AshleyS
                                                                                                                                                          Participant

                                                                                                                                                            Hey Josh,

                                                                                                                                                            I'm not a huge help but the advice you've received is great. It's so tough knowing what step to take. Although my kiddos are too young for "the talk," I remember all the thoughts I had when my health was bad. I often talked to God (in my head) and felt that I wasn't afraid to die, but I was afraid of what my family would go through if I did. 

                                                                                                                                                            My husband and I are in Houston right now through Monday. If you're still around and need anything – coffee delivered, a movie night, or two sets of ears to listen, please don't hesitate to reach out. 

                                                                                                                                                            Ashley

                                                                                                                                                            701-721-6177

                                                                                                                                                            AshleyS
                                                                                                                                                            Participant

                                                                                                                                                              Hey Josh,

                                                                                                                                                              I'm not a huge help but the advice you've received is great. It's so tough knowing what step to take. Although my kiddos are too young for "the talk," I remember all the thoughts I had when my health was bad. I often talked to God (in my head) and felt that I wasn't afraid to die, but I was afraid of what my family would go through if I did. 

                                                                                                                                                              My husband and I are in Houston right now through Monday. If you're still around and need anything – coffee delivered, a movie night, or two sets of ears to listen, please don't hesitate to reach out. 

                                                                                                                                                              Ashley

                                                                                                                                                              701-721-6177

                                                                                                                                                              Scooby123
                                                                                                                                                              Participant

                                                                                                                                                                Keep strong Josh, thinking of you and sending a big hug x

                                                                                                                                                                scooby x

                                                                                                                                                                Scooby123
                                                                                                                                                                Participant

                                                                                                                                                                  Keep strong Josh, thinking of you and sending a big hug x

                                                                                                                                                                  scooby x

                                                                                                                                                                  Scooby123
                                                                                                                                                                  Participant

                                                                                                                                                                    Keep strong Josh, thinking of you and sending a big hug x

                                                                                                                                                                    scooby x

                                                                                                                                                                    ed williams
                                                                                                                                                                    Participant

                                                                                                                                                                      Hi Josh, I don't know if I have given this link before but it features Dr. Omid Hamid speaking about future and current treatment for melanoma. The video is from Oct 2016 and is very positive about all the options that are opening up for us all. Best Wishes!!! Ed    https://www.youtube.com/watch?v=FtQJQhQE3dQ

                                                                                                                                                                      ed williams
                                                                                                                                                                      Participant

                                                                                                                                                                        Hi Josh, I don't know if I have given this link before but it features Dr. Omid Hamid speaking about future and current treatment for melanoma. The video is from Oct 2016 and is very positive about all the options that are opening up for us all. Best Wishes!!! Ed    https://www.youtube.com/watch?v=FtQJQhQE3dQ

                                                                                                                                                                        ed williams
                                                                                                                                                                        Participant

                                                                                                                                                                          Hi Josh, I don't know if I have given this link before but it features Dr. Omid Hamid speaking about future and current treatment for melanoma. The video is from Oct 2016 and is very positive about all the options that are opening up for us all. Best Wishes!!! Ed    https://www.youtube.com/watch?v=FtQJQhQE3dQ

                                                                                                                                                                          jenny22
                                                                                                                                                                          Participant

                                                                                                                                                                            Hi Josh-

                                                                                                                                                                            Just reading this for the first time today…..I dont have specifics to offer but it looks like you have received a good bit of info and great suggestions from so many here.

                                                                                                                                                                            I cant imagine how you are feeling, and know you've had SO many ups and too many downs….but as others have said, you are not out of options, so i am sending my VERY BEST thoughts that the next one will give you a good, and durable response.

                                                                                                                                                                            Sending you all my best wishes…..

                                                                                                                                                                             

                                                                                                                                                                            jenny

                                                                                                                                                                             

                                                                                                                                                                            jenny22
                                                                                                                                                                            Participant

                                                                                                                                                                              Hi Josh-

                                                                                                                                                                              Just reading this for the first time today…..I dont have specifics to offer but it looks like you have received a good bit of info and great suggestions from so many here.

                                                                                                                                                                              I cant imagine how you are feeling, and know you've had SO many ups and too many downs….but as others have said, you are not out of options, so i am sending my VERY BEST thoughts that the next one will give you a good, and durable response.

                                                                                                                                                                              Sending you all my best wishes…..

                                                                                                                                                                               

                                                                                                                                                                              jenny

                                                                                                                                                                               

                                                                                                                                                                              jenny22
                                                                                                                                                                              Participant

                                                                                                                                                                                Hi Josh-

                                                                                                                                                                                Just reading this for the first time today…..I dont have specifics to offer but it looks like you have received a good bit of info and great suggestions from so many here.

                                                                                                                                                                                I cant imagine how you are feeling, and know you've had SO many ups and too many downs….but as others have said, you are not out of options, so i am sending my VERY BEST thoughts that the next one will give you a good, and durable response.

                                                                                                                                                                                Sending you all my best wishes…..

                                                                                                                                                                                 

                                                                                                                                                                                jenny

                                                                                                                                                                                 

                                                                                                                                                                                jbronicki
                                                                                                                                                                                Participant

                                                                                                                                                                                  If you need ANYTHING while you are at MDA, my number is 248-207-1520/713-743-5775 and email is [email protected].  we work and live right by there and I have friends who are medical librarians there who can tap into the research services and doctors in the Medical Center if we need to get a network going to get you the answers you need.  Although, Ed, Bubbles, etc are pretty darn AMAZING and comprehensive in that department.  My husband and I are more than willing to help in any way possible.  We have a network here in Houston if you need anything.  

                                                                                                                                                                                  (totally get the fear for the kids, any parent understands that's THE biggest fear!  We don't want to hurt them in any way, but they obviously have a great dad which is the most important thing, so try to remember that!)

                                                                                                                                                                                  Hugs,

                                                                                                                                                                                  Jackie

                                                                                                                                                                                  jbronicki
                                                                                                                                                                                  Participant

                                                                                                                                                                                    If you need ANYTHING while you are at MDA, my number is 248-207-1520/713-743-5775 and email is [email protected].  we work and live right by there and I have friends who are medical librarians there who can tap into the research services and doctors in the Medical Center if we need to get a network going to get you the answers you need.  Although, Ed, Bubbles, etc are pretty darn AMAZING and comprehensive in that department.  My husband and I are more than willing to help in any way possible.  We have a network here in Houston if you need anything.  

                                                                                                                                                                                    (totally get the fear for the kids, any parent understands that's THE biggest fear!  We don't want to hurt them in any way, but they obviously have a great dad which is the most important thing, so try to remember that!)

                                                                                                                                                                                    Hugs,

                                                                                                                                                                                    Jackie

                                                                                                                                                                                    jbronicki
                                                                                                                                                                                    Participant

                                                                                                                                                                                      If you need ANYTHING while you are at MDA, my number is 248-207-1520/713-743-5775 and email is [email protected].  we work and live right by there and I have friends who are medical librarians there who can tap into the research services and doctors in the Medical Center if we need to get a network going to get you the answers you need.  Although, Ed, Bubbles, etc are pretty darn AMAZING and comprehensive in that department.  My husband and I are more than willing to help in any way possible.  We have a network here in Houston if you need anything.  

                                                                                                                                                                                      (totally get the fear for the kids, any parent understands that's THE biggest fear!  We don't want to hurt them in any way, but they obviously have a great dad which is the most important thing, so try to remember that!)

                                                                                                                                                                                      Hugs,

                                                                                                                                                                                      Jackie

                                                                                                                                                                                      Maria C
                                                                                                                                                                                      Participant

                                                                                                                                                                                        Hey Josh, it sounds like you have a plan in place and you're off to make it happen tomorrow? It's been awhile since I visited these boards and while it's so good to hear from you I'm sorry it has to be about this.

                                                                                                                                                                                        Just wanted to send you my thoughts: I've had both gamma knife and cyber knife and prefer cybernife but either/or will deliver the first punch. The second punch I imagine would be ipi/nivo within a couple weeks since you haven't tried that combo yet. The one-two punch of SRS + radiation could be just what knocks down the beast for you!

                                                                                                                                                                                        You got this one Josh. After all you've been through, you'll get through this one too. 

                                                                                                                                                                                        Prayers & thoughts & BIG HUGS!!!

                                                                                                                                                                                        Maria C
                                                                                                                                                                                        Participant

                                                                                                                                                                                          Hey Josh, it sounds like you have a plan in place and you're off to make it happen tomorrow? It's been awhile since I visited these boards and while it's so good to hear from you I'm sorry it has to be about this.

                                                                                                                                                                                          Just wanted to send you my thoughts: I've had both gamma knife and cyber knife and prefer cybernife but either/or will deliver the first punch. The second punch I imagine would be ipi/nivo within a couple weeks since you haven't tried that combo yet. The one-two punch of SRS + radiation could be just what knocks down the beast for you!

                                                                                                                                                                                          You got this one Josh. After all you've been through, you'll get through this one too. 

                                                                                                                                                                                          Prayers & thoughts & BIG HUGS!!!

                                                                                                                                                                                          Maria C
                                                                                                                                                                                          Participant

                                                                                                                                                                                            Hey Josh, it sounds like you have a plan in place and you're off to make it happen tomorrow? It's been awhile since I visited these boards and while it's so good to hear from you I'm sorry it has to be about this.

                                                                                                                                                                                            Just wanted to send you my thoughts: I've had both gamma knife and cyber knife and prefer cybernife but either/or will deliver the first punch. The second punch I imagine would be ipi/nivo within a couple weeks since you haven't tried that combo yet. The one-two punch of SRS + radiation could be just what knocks down the beast for you!

                                                                                                                                                                                            You got this one Josh. After all you've been through, you'll get through this one too. 

                                                                                                                                                                                            Prayers & thoughts & BIG HUGS!!!

                                                                                                                                                                                            Momofjake
                                                                                                                                                                                            Participant

                                                                                                                                                                                              Josh,

                                                                                                                                                                                              we had a similar week unfortunately. Jake found out Wed he has 3 small brain mets on the right side. His upper spine now hurts pretty bad and is restricting his activity. How to stay positive?? I don't know, ask Jake. He is. He was hit hard and was very sad. But he still believes he can get well. Did his first dose of ipi and checking into radiation tomorrow. Josh, it's hell, it's lonely and I really hope prayers, love and knowing so many are doing the same day to day helps a little! I hope you can get ahead of this and Josh, you keep trying as long as you can endure!! 

                                                                                                                                                                                              ❤️ Kerri

                                                                                                                                                                                              Momofjake
                                                                                                                                                                                              Participant

                                                                                                                                                                                                Josh,

                                                                                                                                                                                                we had a similar week unfortunately. Jake found out Wed he has 3 small brain mets on the right side. His upper spine now hurts pretty bad and is restricting his activity. How to stay positive?? I don't know, ask Jake. He is. He was hit hard and was very sad. But he still believes he can get well. Did his first dose of ipi and checking into radiation tomorrow. Josh, it's hell, it's lonely and I really hope prayers, love and knowing so many are doing the same day to day helps a little! I hope you can get ahead of this and Josh, you keep trying as long as you can endure!! 

                                                                                                                                                                                                ❤️ Kerri

                                                                                                                                                                                                Momofjake
                                                                                                                                                                                                Participant

                                                                                                                                                                                                  Josh,

                                                                                                                                                                                                  we had a similar week unfortunately. Jake found out Wed he has 3 small brain mets on the right side. His upper spine now hurts pretty bad and is restricting his activity. How to stay positive?? I don't know, ask Jake. He is. He was hit hard and was very sad. But he still believes he can get well. Did his first dose of ipi and checking into radiation tomorrow. Josh, it's hell, it's lonely and I really hope prayers, love and knowing so many are doing the same day to day helps a little! I hope you can get ahead of this and Josh, you keep trying as long as you can endure!! 

                                                                                                                                                                                                  ❤️ Kerri

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                                                                                                                                                                                              The MRF Patient Forum is the oldest and largest online community of people affected by melanoma. It is designed to provide peer support and information to caregivers, patients, family and friends. There is no better place to discuss different parts of your journey with this cancer and find the friends and support resources to make that journey more bearable.

                                                                                                                                                                                              The information on the forum is open and accessible to everyone. To add a new topic or to post a reply, you must be a registered user. Please note that you will be able to post both topics and replies anonymously even though you are logged in. All posts must abide by MRF posting policies.

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