What happens after you've been diagnosed with cancer?

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Transcript

Tessa Lackey:

Have you or a loved one recently been diagnosed with cancer and wondering, "Now what?" Hello, and welcome to Prescribed Listening by UToledo Health. I'm your host, Tessa Lackey. Today we're talking to Dr. Mersiha Hadzi from the Department of Radiation and Oncology and Dr. Danae Hamouda from the Department of Oncology and Hematology at UToledo Health. Dr. Hamouda And Dr. Hadzi discuss what comes next and what you can expect if you end up receiving radiation therapy or chemotherapy as the best form of treatment for you. One of the things I also love about this episode was how Dr. Hamouda and Dr. Hadzi emphasized that you are not alone in your treatment at UToledo Health and how they're on your team. So without further ado, let's get into our discussion.

Dr. Hadzi, Dr. Hamouda, thank you so much for joining us today. So if you could both tell us what you both do for UToledo Health.

Dr. Mersiha Hadziahmetovic:

Thank you so much, Tessa. My name is Mersiha Hadziahmetovic. I'm known as Dr. Hadzi. I am the Clinical Service Chief of the Department of Radiation Oncology at the Dana Cancer Center. I'm also an Associate Professor in the College of Medicine. I'm a full-time clinician. I see patients five days a week. The vast majority of my patients have a malignant condition for which radiation therapy is indicated as part of treatment, and that's what I do.

Tessa Lackey:

And then, Dr. Hamouda?

Dr. Danae Hamouda:

Yeah, thanks for the invitation, Tessa. It's good to be back. So I'm Danae Hamouda. I'm a Medical Oncologist by training, so I spend most of my time helping patients with cancer. I'm also the Fellowship Program Director for our Hematology and Medical Oncology Fellows and I'm the Service Chief for the HemOnc Service Line.

Tessa Lackey:

Most likely, people who are listening to this episode are hearing it after they've received a cancer diagnosis and are processing it after that original appointment. And they may be working through what those next steps are going to be and just processing the information itself. So what are some things that people can expect to come with this diagnosis?

Dr. Mersiha Hadziahmetovic:

So I think any cancer diagnosis is first of all an individual's diagnosis, but also many times a family's diagnosis. It really impacts not just the patient but their loved ones as well. Thinking of when we have a tissue diagnosis of a malignant condition, we go kind of from zero to 60 to what I like to say, complete the puzzle in terms of what is referred to as staging to see what is this type of cancer. We know it's so-called natural history, we know what it likes to do. We want to see how far along has it spread, because that really informs what we call clinical decision-making. We have to complete the puzzle in order to recommend what's considered the best standard of care for you for that stage of disease.

So lots of things happen. You're seeing multiple doctors because cancer care is a team sport, and you get introduced to your entire team probably within a span of one to two weeks. And it can be very bewildering to go through that for the patient. Lots is happening. But by asking questions, getting clarifications, you are in for a ride with the rest of your medical team. The patient is the most important part of that team. We pride ourselves on delivering patient-centered compassionate care that follows the best standards of care in 2024.

Tessa Lackey:

Dr. Hamouda, anything you'd want to add?

Dr. Danae Hamouda:

Yeah. So yes, oftentimes this diagnosis is a shock. So it's not something that someone's expecting, and for many people this is a life-changing kind of diagnosis. So there's all of this processing of something so stressful that they're going through coupled with our zero to 60, trying to get an idea of how the cancer behaves and how involved the cancer is, where the locations are, which helps us to determine the types of treatment that may be more effective and coming together for a treatment plan, whether that's something we are looking to cure or something that we're looking to control and really partnering with the patient. So it's a whirlwind, I think, of emotions in a very, very difficult time, especially in those first two weeks. It can feel like limbo, wanting all of the answers of what things are, where they are, what our plans are, but really important to have all of the information together to make a good decision in a short timeframe.

Tessa Lackey:

So what are some ways that you both would recommend with coping with this diagnosis? Dr. Hamouda, do you want to start?

Dr. Danae Hamouda:

Yeah. So coping with such a life-changing diagnosis really can be different for each person. But I would first say whatever you're feeling is okay, and it's normal to have a lot of emotions going through something so stressful and potentially life-changing. Very common to feel the big wide range of emotions: anxiety, fear, denial, guilt, feeling of helplessness, that's all very, very natural. So you're not alone feeling with those feelings and it's okay to feel that way. And then, some days are tough and some days are better, but to always know that you're not alone on the journey ahead and to work through ways to cope through some of those feelings.

I don't know, some of the patients seem to really benefit from journaling or finding a way to express feelings. So sometimes that's through journaling, sometimes it's through sharing with one specific support person or a group of friends. For some people that's going to support groups such as community-sponsored support groups, or even with a counselor or the physician team; all good places to go to kind of express your feelings and to work through what you're going through.

Knowledge can be empowering, so learning about your cancer and the options that you have, that can really help you feel a little bit of a sense of control again when you feel quite kind of lost in this whirlwind. So I think those are my two main pieces of advice, is it's okay to feel what you're feeling and express that, and then try to get to know what you can about the situation that you're facing.

Dr. Mersiha Hadziahmetovic:

Everything that Dr. Hamouda says, a hundred percent agree. I think patients cope differently at different phases of their journey with cancer. As I mentioned earlier, it is bewildering, it's confusing. You're angry, you're upset. But then, the more you understand your disease process, the more you are an integral part of your own medical team, the more you understand the strategy of how we handle this, you, I think, gain a certain level of comfort and then settle back into things that helped you get through other hard things in your life.

We all have hard things in our lives. We know how we cope. There are good ways to cope with difficult things in life and not so good ways. I typically tell patients, "Be open, be honest, speak with your loved ones. You know what works for you. Control what you can control: your nutrition, your physical activity, your sleep, physical, mental, spiritual, emotional health." All of that I think can make a patient a good strong specimen to try aggressive therapy on. And that's how they meet us halfway, all toward a goal of giving them the best possible outcome that modern medicine can accomplish.

Tessa Lackey:

What are some examples that both of you have seen from past patients that really helped them kind of get through this? We talked about journaling and we talked about finding a support person and talking to a counselor and then looking for community support groups. I guess is there anything else that you've seen just from different experiences with people that there was something that really helped them that may help someone out that is listening to this?

Dr. Mersiha Hadziahmetovic:

That's a really good question. I think the patients that I see who deal with it in a very healthy way, they acknowledge, "Okay, I have cancer. I get it. I understand. This is how far along it is. This is what we're doing." They acknowledge it, they accept it, they deal with it, but they go on with their life. They don't let cancer put brakes on their life, on their dreams, their aspirations. And they don't make the diagnosis into this all-consuming thing. It doesn't become a huge part of their identity. There's way more facets to their identity than just being a patient with cancer.

And I think that's a really mature and healthy way to address difficult things in life. There's more to you than just your diagnosis. You're showing up for yourself. We are here with you every step of the way. We're not wavering in our support for you. Let us do the heavy lifting of finding out what the best treatment for you is and delivering the said treatment. You do what you can do to make sure you're strong enough to withstand the treatment that you need and live your life. I think that is really an empowering way to take control of the narrative of this diagnosis in your life. And time and again, that seems to be like the winning strategy, I think.

Tessa Lackey:

Yeah, I love that. I love that. Even similarly to when other different parts of your life are happening, whether you become a parent or you become a caregiver or something new part of your identity comes in, there is more to you than just a cancer diagnosis. You are not this disease.

Dr. Mersiha Hadziahmetovic:

Absolutely, a hundred percent.

Tessa Lackey:

Yeah, I love that. Anything you'd want to add, Dr. Hamouda?

Dr. Danae Hamouda:

Yeah, yeah. Being a survivor is just a small piece of it, so keeping all of those other aspects that make you who you are. Some days you're going to feel more like a person who is surviving with cancer, and some days you're going to feel like a coach or a dad or a musician or whatever other pieces define you, to continue to kind of lean into those. I think that was really helpful too.

Tessa Lackey:

I would think with getting this diagnosis, and I know this is something that I would even do. After my appointment, I would start turning to the internet and looking up different things and just diving down a rabbit hole of research. What would you recommend or what would be your advice to people who are taking to the internet and just losing it down there?

Dr. Danae Hamouda:

Or even before they come to meet us, we have access to our health records, so sometimes our patients are finding these diagnoses by logging into their chart. And that can be a really, really scary moment or few days until you connect with your physician. I would just be careful about what you're reading. Medical language is a totally different language altogether, so really take it with a grain of salt. It may not be the worst case scenario, which is what our brains tend to move towards, but to try to acknowledge that there's something that we need to talk about, and put your list of questions together and to bring it to your physician and really have that discussion.

Reading on Google, looking on good sites that have EDU or .gov or .net, they can all be helpful, but a lot of what's written on there can be a little bit outdated experiences. In cancer care, things just continue to evolve, and we're doing our best to individualize and improve outcomes, and that's all moving forward. And a lot of what you're looking at on the internet is looking backwards, so just be really kind of cautious about what you'd read about and bring any questions, write them down, bring them to the visit and we'll be happy to discuss.

Dr. Mersiha Hadziahmetovic:

Not all information is knowledge, not all of it is useful, and you really need a shepherd. Your oncology team is like your shepherd, okay, through this vast sea of information. There are some excellent websites, reputable sources, videos even from reputable places that can with visual aids help, especially visual learners understand some concepts better.

We would recommend that we guide you to them as opposed to going on Reddit or Google or talking to somebody who, for example, had cancer treatment 20 years ago. If they start saying unfavorable things, obviously if the person is alive 20 years later, clearly the treatment worked, but sometimes they beat up on the treatment modalities like chemotherapy or radiation. The newly diagnosed patient may have a completely different malignant process, may require a completely different treatment plan than what was done 20 years ago. So I like to use the analogy of a horse buggy and a Tesla. We live in a Tesla era. Don't use information from the horse buggy era to judge the treatments from the Tesla era. They're very different, and you have to be very discriminating where you go for information, what you absorb, who you listen to, and not everything out there is useful.

Tessa Lackey:

So essentially, part of what I'm hearing here is because cancer is evolving so much, not all of it is accurate on the internet. And because everyone's cancer treatment is individual to themselves, not all of it may apply to them as well. Okay. If there is, let's say they did find a blog or some kind of article that someone finds this and they're like, "This sounds just like me and I really trust it." Can they bring that article into you with their questions as well and talk about it?

Dr. Mersiha Hadziahmetovic:

The patient can bring any questions, any resources. That's part of building this very sacred bond called doctor-patient relationship. And though the nuts and bolts of medicine, it's a very sacred relationship. It means something. Of course, they can ask any questions and we are there to help verify it or debunk it and tell them how it may be similar versus different to whatever they might go through.

Tessa Lackey:

Circling back a little bit to journaling, I once heard someone talk about journaling as a way to track your symptoms of your mental health. Like you would track your symptoms of whatever your body is feeling, you can use journaling to track whatever's going on in your head in a similar way as well too. Would you say that journaling is kind of like that?

Dr. Danae Hamouda:

Yeah, absolutely. And it's no pressure, so it can be private, it can be something you share. You may just put words on a page of how you're feeling or nouns of what you're seeing and going through. And just having that quiet space to process it I think is really helpful. For some, that's through drawing, poetry, journaling, talking, but that can be really helpful.

Tessa Lackey:

So let's discuss some recommendations on how to talk to loved ones specifically about this new diagnosis. So would you have any recommendations for how these patients can discuss this with friends and families specifically? Dr. Hamouda, if you want to start?

Dr. Danae Hamouda:

Yeah. Oh boy, that's tough. You're going through all of this, trying to process it, and sometimes you can feel that weight of having to share such a diagnosis with somebody that you love. It can be really difficult. So being kind of mindful about the setting and making sure you have time and space to have a conversation with that person.

For many people, that first person they tell is their largest support person, their best friend, sometimes their spouse, their child, their parent. And just having some quiet protected space to talk about what you know, what you don't know, and be prepared for an emotional reaction from your loved one and acknowledge and that's okay. And just to kind of be there together.

One thing that I think we may struggle with is asking for help. Our friends, our family, they want to help. Sometimes they don't know how. And so, if there are ways that you would like them to be active or be your support person in a specific way, sharing what they could be helpful with can be important. If it's transportation or it's running errands or it's just being someone that will listen to you vent or just being together, all of those things are really important. And sometimes it takes some specific discussions on that so you both can do what you'd like to do.

Tessa Lackey:

In this stage where they are working to lean on different friends and family or whatnot, they just aren't the kind of person that likes to ask for help and they don't want to talk about what's going on. So what would you recommend people who are like that and who are the opposite of someone that's saying, "This is what I need" and delegating what they need?

Dr. Mersiha Hadziahmetovic:

Yeah. Everybody's a little bit different, different personalities, different temperaments. Some people are more private than others and they don't want this big, what we perceive as fanfare, they don't want the colored ribbons. They think it's juvenile to just dress all in pink or whatever the color of the month is. But that's their way, right? A pat on the shoulder, leaving a warm meal outside of their door, but not really expecting to get into a conversation, clearing the snow, these are the things patients like this probably value. Acts of service without, or just like on your own, self-initiative, you can do without waiting for them to ask. So I think if somebody really wants to do something for a newly diagnosed patient or patient who is maybe not newly diagnosed but is in a different stage of their journey with cancer, there's always ways. I wouldn't recommend, "Hey, let me know if I can help you in any way." Just if you know that person, figure out a way to do something for them and just do it.

Tessa Lackey:

Yeah. Know who you're talking to. Essentially, know who you're working with. I think that makes sense too.

Dr. Mersiha Hadziahmetovic:

I think as far as talking with family, loved ones, be honest. Bring them to your appointments if you feel comfortable with that. Use clear, simple language. I think when you have to break the news to your children, the C word, the word cancer really elicits a visceral response in your average person, right? So I think with children, you should also be honest and be deliberate. Maybe give them smaller bites of information in a language that is suitable to their age and understanding. And check in with them regularly, open that line of conversation because they might be hesitant to ask questions and inquire about maybe scary prospect of their parent not doing well, for example.

Tessa Lackey:

Okay. Dr. Hamouda, anything you'd want to add about breaking this news to children or to someone's children?

Dr. Danae Hamouda:

Yeah. Oh, that can be really, really difficult no matter the age of your children. I think sometimes the internet can be helpful in this circumstance, seeing what worked for other people. You know your family, and you may know the approach to take, so that can be helpful for what's worked for some.

Tessa Lackey:

Let's get into types of cancer treatment. So we talked about how once you get into this initial appointment of "You have cancer," that we go from zero to 60 with everything. So Dr. Hamouda, would you want to talk about the avenue of if someone is receiving chemo?

Dr. Danae Hamouda:

Yeah. So once you go through that whirlwind of diagnosis and we get to understand how that cancer behaves as well as the stage or location of the cancer, we typically will then be able to have a discussion as to what our goals of treatment are, whether that is something we're hoping will be curable or something that we intend to try to control with good quality of life. And so, I think that's kind of the first part of the discussion, is discussing what we know, where we are right now, and what the potential prognosis can be.

And then, we often discuss different types of chemotherapies for different stages and types of cancer. There are so many types of treatments that we have and we kind of lumped them all into this chemotherapy. Just really any medication that we use to treat cancer kind of colloquially falls into this term. So lots of different options of things that could be discussed. There are a lot of good supportive meds. The treatments that we use now are vastly different than what we've used even a decade ago, and our supportive management has improved. So the discussion about what you might expect with the side effects and the benefits would be had usually by maybe the third or so time that you meet after getting to know more about the cancer and the prognosis, and then coming with a decision that makes the most sense for each individual person. Sometimes that's keeping in mind what is the priority and the values of the patient? What are the potential side effects? And then, what are the benefits? So it's a lot of balanced discussions when individualized for each person.

Tessa Lackey:

And then Dr. Hadzi, do you want to talk about if someone is receiving radiation, what would that look like?

Dr. Mersiha Hadziahmetovic:

Sure. Yeah. So I always like to use the analogy of the Armed Forces: the Army, Navy, Air Force to highlight how your oncology team is a team sport. We're kind of like Armed Forces. The surgeons are the Army, medical oncologists are the Navy, and the radiation team is the Air Force. And you sometimes have to deploy different flavors of the Armed Forces as a best strategy against a certain malignancy.

So with radiation, radiation is a very scary word. The leaders in our field say we have a PR problem. But radiation, the one that's most commonly employed, is really just high energy x-rays. X-rays were discovered in 1895. It was such a gift to humanity. That that's how the first Nobel Prize went to the physicist who discovered these, X as an unknown entity, X-rays, and they're amazing at killing cancer.

The 20th century was all about figuring how do we harness the power of these incredible rays to get the job done safely? Right? So it's all about, we have these sophisticated machines called linear accelerators, and these linear accelerators and make these very high energy X-rays that can be shaped and pointed into beams toward the tumor very accurately, very precisely. And then, the X-ray energy chops up the DNA in the cancer cell, and that's how we kill the cancer cell.

The side effects typically depend on where is the tumor? How large is the tumor? What dose do we need to deliver to the tumor? What is adjacent to the tumor, meaning what will get some stray dose adjacent to the tumor? And our textbooks have that information because that's all from decades and decades of research done in the 20th century.

Nowadays, radiation treatments are typically very effective, very safe, and they truly help people. They help stop bleeding very readily. They alleviate pain. They shrink the tumors. They make it harder for the tumor to grow, put brakes on it. All of that translates into a better quality of life and oftentimes improved survival. And that's why it's a pillar of cancer care.

Tessa Lackey:

Is there anything that you feel like you would want to touch on again, between chemo and radiation, just to give people who are, again, new to this, just to give them a taste of what could be happening?

Dr. Mersiha Hadziahmetovic:

It really is an individual treatment plan and side effect profile, as we like to say. It is difficult to kind of say, "All of you people receiving radiation will get XYZ," because that may not be the case.

Tessa Lackey:

And Dr. Hamouda, anything else you'd want to add?

Dr. Danae Hamouda:

Yeah. So chemo is a big term, talking about any type of medication that we use to help treat cancer. And that comes in many different mechanisms as well as different formulations. So sometimes that includes medications that come in pill form, sometimes that's through injections, sometimes it's through IV form. So it's highly variable depending on what type of medication we're using. And there's lots of different mechanisms as to how these medications work. So our kind of traditional chemotherapies are the ones that directly cause cell damage and kill cells, and can kill some of the normal cells as a byproduct and can lead to some of the side effects that are more maybe what you naturally think about when you hear the word chemotherapy.

So we have those drugs that directly kill, maybe more indirectly kill, and then we have antibodies. And what these do is they can enhance your immune system for recognizing things. It can bring two different types of cells together, your cancer cell and your immune system cell. It could bring your immune system to recognize cancer cells. It can bring kind of a targeted chemotherapy directly to the cells that have that antigen.

So there's a lot of different mechanisms, a lot of different options for treatment. The side effects you can imagine, will be very much different, the dosing and the profiles for those. So it's really individualized, but there's a lot of different options ranging from pills to several different types of chemo to antibodies and everything in between.

Tessa Lackey:

So what are some good questions to keep in mind when meeting with your care team? We discussed how this is probably a good time to turn to Google, looking up some different questions that may be helpful. Is there any questions that you've heard with different patients that you thought was really helpful or that you would recommend people to ask?

Dr. Mersiha Hadziahmetovic:

So I always really want to make sure that the patient in front of me has that we are on the same page, in lockstep every step of the way. And I will repeat the same thing in multiple different ways until the light bulb moment occurs.

So I think when the diagnosis is first established, some kind of basic question, "What kind of cancer do I have? How far along is it, meaning what stage is it? What next? What is the intent of treatment? Are you trying to cure me? Are you just trying to make me feel better, i.e. control it, or maybe alleviate a bothersome symptom?" for example, coughing up blood. So intent of treatment. "What does the treatment entail? How are we going to put our ducks in order? What can I reasonably expect while on treatment?" For patients who work, "Will I be able to work? Do I need to take time off?"

A lot of patients are surprised that they can work through their radiation course, even though radiation is in most of the cases delivered Monday through Friday every day for a few minutes. But it's completely non-invasive. There's no needles, there's no anesthesia. We have patients who are construction workers, security personnel, teachers, professors, etc., who you show up for their 15-minute time slot, get their treatment, get back to work. All of those are excellent options to kind of paint a picture of what your average day might look like.

I think with chemotherapy, I'll defer that to Dr. Hamouda because I think on the infusion day, if it's an intravenous formulation, you might have to actually take a day off, how you'll feel a few days later. So I'll let her answer that.

Dr. Danae Hamouda:

Yeah. "What can I expect? What are my side effects? What are you anticipating my side effects will be? How does the trajectory look over time?" I think that's really an important part of the conversation. I always encourage the patients to ask me about, "What options do I have?" Because there is no one correct answer. There's no one size fits all. So having that conversation about what the options are, what the risks and benefits are can help lead to a well-informed decision, both in the immediate future and then the long-term side effects.

I think one question I don't hear that often, but I'll bring up is, "Would a clinical trial be right for me?" So the pace of oncology moves very quickly, and our standard of care continues to evolve. But there are some times when a clinical trial can be really helpful. This is how we move field forward and how we've seen such expansive growth in oncology, especially in the last decade. So that's a good question to ask in different time points. "What about a clinical trial?"

Dr. Mersiha Hadziahmetovic:

Absolutely, yes. I always say clinical trials are a chance to have tomorrow's treatment today. We've made amazing headways in pediatric cancer, honestly because 90% of children with cancer are enrolled on some sort of clinical trial. In adults, I think it's less than 5%. The vast majority of adult patients are not on a clinical trial. So how do you move the needle if we can't conduct an experiment, a trial, with some possible new better treatment, tomorrow's treatment today, to prove that it is better than what we're offering today?

So I think that's something that's universally the case in this country. Maybe our inclusion criteria are too strict. Maybe we just take too many people out of the running for clinical trial. But some really smart people are working on that to make clinical trials more accessible to more patients with cancer. They don't all have to be marathon runners to enroll, or they shouldn't be. We could enroll maybe the wheelchair-bound grandma if the experimental drug has not been shown to be toxic. The future is exciting, but yes, clinical trials absolutely is a chance to have tomorrow's treatment today.

Tessa Lackey:

Would you say for those people that are hearing this about clinical trials and they're like, "I don't know. That makes me nervous." When considering a clinical trial, what should people take into account and remember when it comes to that? I love the example that you gave about how this is tomorrow's treatment today as well. But what else would you say about...

Dr. Danae Hamouda:

Yeah, the idea of a clinical trial can be really intimidating. There's a lot of preconceived ideas about what that entails. The trials, there's lots of different options. There's some at different phases where we're looking at safety, some where we're looking at efficacy, different mechanisms of action, different side effect profiles, the amount of time that may be required as part of that enrollment. So those are all discussions. But at least to be open to that consideration, because we are trying to refine our management for patients, not to treat too much or too little, but to find that kind of Goldilocks. And part of how we get to that individualized goal is through these trials and gaining more insight into the efficacy and side effects of some of these newer drugs as well.

Dr. Mersiha Hadziahmetovic:

And I think it's also a chance to pay it forward to the future patients as well. I think some people are really motivated by that. They're like, "What can I do? How can I..." I think sometimes when patients are diagnosed with cancer, the light switch goes on and they're just like, "I want to do more. How can I be of use to greater use to society?" This is a great way, honestly. You're helping answer a very critical question that hopefully will help you, but it'll also definitely help people who are coming after you who may be diagnosed with the same process years later. I think some patients are moved by that.

Tessa Lackey:

Yeah, an element of purpose. I love that. Is there anything else you would both want people specifically to know regarding a new cancer diagnosis and anything that you would want patients to know outside of what we've already discussed?

Dr. Mersiha Hadziahmetovic:

So I'll quote one of my idols, the mother of our field, Madame or Marie Curie. But Madame Curie said, "Nothing in life is to be feared. It is only to be understood." And I think the C word is very scary, but we will help you understand it. It is what we do day in, day out. We've all gone to school for a quarter of a century to understand this. And we're on your team. We'll hold your hand throughout, and we want to make it less scary and something very manageable for you.

Tessa Lackey:

So that you can continue living your life.

Dr. Mersiha Hadziahmetovic:

Yes.

Tessa Lackey:

Dr. Hamouda, anything else you'd want to add?

Dr. Danae Hamouda:

Whatever you face in the days ahead, you've got a good team around you and a good support person. When things go well, we're happy. When things don't go as well as we hope, we still are with you through whatever the journey lies ahead. So finding that group of people to help support you through this tough time can really be invaluable.

Tessa Lackey:

Thank you again for joining us, Dr. Hamouda and Dr. Hadzi. And thank you for listening. If you would like to schedule an appointment with Dr. Hamouda or Dr. Hadzi, you can call the Eleanor N. Dana Cancer Center at 419-383-6644. We've also listed that number in our show notes. And don't forget to hit subscribe before you go so you don't miss any future episodes with Dr. Hamouda, Dr. Hadzi, or any of our other UToledo health providers.