publication date: May. 17, 2019
Conversation with The Cancer Letter
Libutti: How Rutgers Cancer Institute became a New Jersey-sized colossus
Steven K. Libutti
Director, Rutgers Cancer Institute
When NCI renewed the Comprehensive Cancer Center designation for Rutgers Cancer Institute of New Jersey, it also acknowledged that the institution’s catchment area now covers the entire state of New Jersey, having expanded from roughly three counties around its home location of New Brunswick.
Like an increasing number of cancer centers in the U.S., Rutgers provides oncology services through an integrated care model in partnership with RWJBarnabas Health at its 11 acute-care hospitals across New Jersey.
“While having just received formal NCI recognition of this expansion of our catchment area, we have always made it our responsibility to serve the entire state,” said Steven K. Libutti, director of the cancer center, who also serves as senior vice president of oncology services at RWJBarnabas Health, vice chancellor for cancer programs at Rutgers Biomedical and Health Sciences, professor of surgery at Rutgers Robert Wood Johnson Medical School, and affiliated distinguished professor in genetics at Rutgers School of Arts and Sciences.
Libutti, a surgeon who specializes in endocrine and neuroendocrine tumors and a researcher who studies the tumor microenvironment, came to Rutgers in 2017 and spent that year both preparing for program renewal and developing a strategic planning process across the health system and recruiting leadership and faculty.
“We defined January of 2018 as the start of this integrated model with RWJBarnabas,” Libutti said. “Prior to that, analytic cancer cases at the cancer institute were around 3,000 a year. In 2018, with this new integrated model across the health system, we are at just over 10,000 combined. And again, to put that in perspective, there are 50,000 new cancer diagnoses a year in the state of New Jersey. So, in 2018, we represented approximately 20 percent of the new cancer diagnoses in the state.”
As part of redesignation, NCI has once again signed off on the Rutgers consortium with Princeton University. The Cancer Center Support Grant is for $15.1 million. The amount for the previous five-year project period was $14 million. “Despite fiscal challenges on the part of the NCI, our grant went up nearly 10% this cycle,” he said.
“As a state, New Jersey is actually the fifth in cancer incidence overall in the United States,” Libutti said. “To put that into perspective, the state of New Jersey is a population of about 8.9 million in approximately 8,700 square miles. So, it’s the most densely populated state in the United States. We’ve gone from a much smaller entity now to what I believe is an entity that can have greater positive impact on that population.”
Libutti spoke with Paul Goldberg, editor and publisher of The Cancer Letter.
It’s often said that if you’ve seen once cancer center, you’ve seen one cancer center. With that in mind, can you tell me about Rutgers?
I think that adage is correct, because each center results from the unique situation at the institution, or institutions, where it originates. So, I’ll take just a second to put Rutgers in that context.
The Cancer Institute of New Jersey was born in 1993. It was the result of a P20 planning grant that was awarded in 1992 and launched with the recruitment of Bill Hait who had been at Yale—a medical oncologist, great leader, now at Johnson & Johnson—who came down to New Jersey and helped to build the cancer institute and infuse it with his DNA.
What I mean by that is a strong focus and dedication to having the patient as the centerpiece, making progress in finding new answers to questions that could lead to treatments for the betterment of patients with cancer.
Bill was successful in leading the cancer institute to achieving NCI designation in 1997, just four years after arriving, then having that elevated to comprehensive status in 2002. Bill did a remarkable job of building the center, both physically and in its operational structure.
There was no cancer center building when Bill arrived in ‘93. When he left around 2007, we had a 225,000 square-foot cancer center building in New Brunswick, space in Robert Wood Johnson University Hospital across the street, and a really robust program, but somewhat cloistered. The cancer institute was always known for fantastic science and great progress in translation, but it wasn’t a very large clinical program and had the desire to grow over time. I think it did an excellent job for its size.
Bill left and was succeeded by Bob DiPaola, who successfully navigated the cancer center through a re-designation in 2012, and also did a great job continuing with recruitment of outstanding scientists. He made internationally known cancer metabolism researcher Eileen White his associate director and deputy director for basic science, and really brought together an incredible group.
He successfully achieved recognition from the NCI for the center to add Princeton University as a consortium partner back during its redesignation in 2012.
A very exciting thing happened in 2013, which was the state of New Jersey passed legislation known as the New Jersey Medical and Health Sciences Education Restructuring Act. This really had a dramatic, what I believe, incredibly positive impact on the cancer institute. This involved integration of components of the former UMDNJ, University of Medicine and Dentistry of New Jersey, into Rutgers University. Bob DiPaola provided critical leadership during this integration process.
In 2014, the Cancer Institute of New Jersey moved out from under Robert Wood Johnson Medical School and became an independent institute of Rutgers University, which was very empowering. It essentially gives the institute the opportunity to collaborate with all the schools and institutes throughout Rutgers, which obviously gives tremendous breadth and depth to the science and the scientific collaborations that can take place.
The institute director was elevated to vice chancellor of a new component within Rutgers, called Rutgers Biomedical Health Sciences, led by Chancellor Brian Strom, and had a reporting relationship that was established then directly to the president of the university, Robert Barchi.
What’s really great about that structure is as the institute director, I can work with deans in any of the schools to appoint and recruit faculty. So, when I bring faculty onboard to the cancer institute as resident faculty—which means their “home” physically, administratively, research-wise, and clinically is within the institute—they can have an appointment at any of the Rutgers schools.
I work closely with the deans to make certain that the visions are aligned, and it’s really a win for both the school and the institute.
So, that exciting transformation is what really attracted me to the cancer institute when it began a search in 2016 for a new director. Bob [DiPaola] moved on to be a dean at University of Kentucky, and I was at the time an associate director for clinical services at the Albert Einstein Cancer Center in the Bronx and the director of the Center for Cancer Care at Montefiore. I was incredibly happy there. It was a great program.
I was there a total of eight years, and I think we worked hard to build a really strong cancer program in the Bronx, serving the Bronx and lower Westchester. It was terrific, but this opportunity to come to Rutgers and to lead a cancer institute into its next inflection point of growth, through a partnership with RWJBarnabas Health—the largest health system in the state—was just too exciting to pass up.
Well, that’s my next question. So, I’m realizing that you’ve seen explosive growth now. So, with the addition of Newark and this RWJBarnabas link, you will be going from a not so huge center to something really massive. Can we talk about this growth that’s coming up?
Rutgers Cancer Institute of New Jersey encompasses Rutgers, the largest public research university in the state; Princeton, the largest private research university in the state and our consortium partner; and RWJBarnabas Health, the largest health system in the state, which cares for approximately five million people.
To put that into perspective, the state of New Jersey is a population of about 8.9 million in approximately 8,700 square miles. So, it’s the most densely populated state in the United States. We’ve gone from a much smaller entity now to what I believe is an entity that can have greater positive impact on that population.
When you talk about cancer centers, we often talk about members. As part of the size, here are some statistics, we’re approximately 230 members right now within the cancer institute. We have about $71 million in direct cost cancer-focused research-funding and about $21 million in direct cost funding from the NCI.
My role here is not only the roles I described on the Rutgers side, director of the cancer institute and vice chancellor for cancer programs, but I’m also the senior vice president for oncology services for RWJBarnabas. That’s important when you talk about the size expansion and change, because what that allows is a very close integration and a harmonization of the vision for both the clinical operations across that health system for cancer care services, which fall under my responsibility as the service line leader, and the research vision for basic translational and clinical research, which is my responsibility as institute director.
So, as New Jersey’s only NCI-designated Comprehensive Cancer Center, we have a tremendous platform to advance the vision and the mission, which is essentially to do the highest quality and most impactful science leading towards the most beneficial novel treatments for patients, better approaches at screening and prevention, and education for the population, and we take that responsibility very seriously on behalf of the state.
As a state institution, we receive funding from the state to achieve this mission, and it really is New Jersey-focused. While the scope of our work has national impact, the health system, Rutgers and Princeton are very much focused on the state of New Jersey as our catchment area. In our most recent designation this year from the NCI, we defined, and the NCI approved, the entire state as our catchment area, although we have always treated it as our responsibility.
What was it before?
Before, it had been defined as approximately three-plus counties surrounding the center of the state, where the cancer institute was based, and then a couple of areas peripheral to that.
As a result of the expansion of our programs—especially in population science and clinical trials, the locations of the sites across the health system, both inpatient and outpatient, the fact that the state helps to support us, and the fact that we are the only designated Comprehensive Cancer Center in the state—we believed that our mission and obligation was to serve the entire state. So, we’re now operationally structured to be able to deliver on that effectively.
So, if we were to put this into perspective, how many analytic cases are you getting now and how many will you be getting in the future when your fusion with RWJBarnabas is fully implemented?
The operationalization of our strategic plan for an integrated cancer service line across the health system began in January of 2018.
Prior to that, analytic cancer cases at the cancer institute were around 3,000 a year. In 2018, with this new integrated model across the health system, we are now just over 10,000 cases combined. And again, to put that in perspective, there are 50,000 new cancer diagnoses a year in the state of New Jersey. So, in 2018, we represented approximately 20% of the new cancer diagnoses in the state.
So, are these RWJBarnabas system hospitals a part of a consortium? Are they a part of your CCSG, without being a consortium. How is it structured?
The way I defined it, and the way we’re structured, I’m responsible for cancer services and cancer clinical research across all of the hospitals. All 11 acute care hospitals and the outpatient sites fall under the responsibility of our oncology service line. Therefore, the RWJBarnabas Health System is defined as part of our CCSG.
In order to provide the most advanced care as close to a patient’s home as possible, we conducted an analysis of the cancer service capabilities across the hospitals of our system.
Our mission, or mindset, is that we believe cancer doesn’t travel well, and our goal is to keep New Jersey cancer patients in New Jersey, if they can receive the same exceptional care and access to clinical trial activity as they would if they had to leave the state. So, we try to navigate patients to the closest one of our sites that has the capabilities to deliver exceptional care for them for their particular type and stage of cancer.
We’ve integrated into this a navigation program. Our goal: every cancer patient has a cancer navigator to help guide them through the process. The process that I described makes certain that if a patient with a cancer diagnosis can be given the care and expertise within 20 minutes of where they live, that’s our preference, but if they require multimodality or multi-specialty integration or the most advanced care, such as bone marrow transplant or advanced proton beam therapy, we will navigate them to the location within the system where they can receive that most complex level of care.
How do you keep the electronic part of it, the communications part of it going?
Like any enterprise, as you begin it, you have to leverage the systems and process that’s in existence, so you can start to weave together essentially what looks like a quilt, a patchwork of a systems.
Right now, we have a number of different electronic systems, whether it be electronic health records, or electronic scheduling, or intake centers, etc. What we’re evolving to, and what we’ve just rolled out, is a process to centralize and make common as many of those systems as we can.
We are in the midst of a transition as a health system to a single inpatient and outpatient EMR, and that’s obviously a process that will take a couple of years to be fully implemented, but we’re moving towards a universal means of communicating health information across the system, the cancer program included.
We’ve just rolled out an access center for the cancer program, which allows doctors or patients to have essentially a single-point-of-contact to connect to us. It’s not meant to replace; if you have particular physicians that you feel comfortable with that you’ve been referring to or you are comfortable at one of our particular sites and you know how to access that, that’s all great, but we’re trying to centralize some of those functions, so if the physician isn’t sure where to send a patient or a patient is not entirely sure where to get their care, our cancer call center, our access center, is a resource.
It is staffed by nurse and lay navigators that are very familiar with cancer diagnoses, and the locations where we have various sub-specialty expertise and can help that patient or the referring doctor get connected to the right location within the system to get the level of care that they need.
We’re building and evolving to better harmonize systems across the cancer service line, but it’s going to be an evolution. You start with the systems in place, try to make them work as best as you’re able in order to execute on your vision, but we are evolving towards unified systems and processes. And I am hopeful within the next two to three years, that transition will be complete.
You’re providing cancer care for a huge health system, and of course, it’s a huge challenge that you see throughout oncology now, with the cancer center being basically an element of health systems—this can be a good thing, this can also be a very bad thing. Does it worry you? Do you sleep well at night?
Well, there are plenty of things that interrupt my sleep or down time, not the least of which is making certain that we’re delivering on what we’re here to do, whether it’s, as I mentioned, exceptional cancer care or driving forward research. And I certainly have the concerns of any cancer center director, making sure my faculty are able to be as productive as they can, making sure they have their resources, and making sure, on the clinical side, that access is there, patients are seen in a timely manner, and other related concerns.
What I would say is that I look at this, clearly, as a tremendous opportunity, and I am very fortunate to have an amazing team on both the health system side, and on the Rutgers side. I have an incredible leadership team, both legacy and new recruits over the last two years, that are just absolutely exceptional.
Yeah, I guess I probably asked the question wrong, although it’s wonderful to know this, but I was asking is health systems have different DNA, different priorities, they work differently from academic institutions, or at least so we thought. Is that a concern for you? That’s the part I was wondering about.
Not at RWJBarnabas Health. RWJBarnabas Health, under CEO Barry Ostrowsky’s leadership, is committed to driving the research and academic mission as strongly as it is committed to delivering exceptional clinical care.
It’s a system that is incredibly focused on its community. Community impact is critically important, not just in the delivery of health care, but in bettering communities.
RWJBarnabas is one of the largest employers in the state, it focuses a lot of its efforts in some of the more challenged regions in the state, from a socioeconomic perspective. In Newark for example, RWJBH has major programs focused on job creation and community health.
The system has a greenhouse in Newark, to make certain that healthy vegetables and fruits are made available. It has a van called the WOW Van, [Wellness on Wheels], which travels to areas across the state, with the firm belief that you really have to impact a person’s life and environment to have a positive impact on their health.
Academics and research is of critical importance as well, and that’s what has enabled this partnership between RWJBarnabas Health and Rutgers University, which was formalized by an MAA [master affiliation agreement] that was signed in July 2018.
This partnership essentially created one of the largest academic health systems in the country, and the largest in New Jersey. It is manifested in part by 2,500 practitioners coming together, both from the health system side and the Rutgers faculty side, to work side by side in advancing research, education, and health care delivery across New Jersey.
So, of all the things I have to worry about, of the things that I have to keep me up at night in terms of succeeding in what we’re attempting to execute, I fortunately don’t worry about a misalignment of vision or goals.
I know that the health system shares the goals of its research and academic partner, Rutgers, in terms of the importance of valuing and driving research. The health system has committed an investment of $50 million a year for 20 years to Rutgers to recruit principal investigators across scientific disciplines. That’s $1 billion committed to research, and academic activity.
RWJBarnabas committed $100 million of that investment over five years specifically to advance cancer services and research, to recruit and hire not just clinicians, but basic scientists and investigators.
Again, as I say, if I’m smart, it was because I was smart enough to make the decision to go to a health system and a university that has a shared goal: provide great care for people and do great science, so that you provide even better care in the future.
Could you tell me a little bit about the Princeton consortium and how that works? I’m asking because consortia are probably going to become more and more important in the future for the National Cancer Institute and the cancer centers program. I don’t actually have any way of making that statement myself, but it’s certainly a sense I have.
I think you’re right. And I think what drives that, to a large degree, is there are a lot of potential partners out there that may not have the breadth and depth, or all of the necessary components to be an NCI-designated cancer center, but yet, could be value added to currently designated cancer centers and expand their impact or their expertise in a particular area, and I think that’s a great platform on which we’ve built our consortium relationship with Princeton.
Princeton, as you know, is an outstanding private research institution. Known for exceptional education and incredible research, Princeton doesn’t have a medical school, and Princeton does not have an easy way to translate its findings or have its scientists and investigators interested in cancer research create those critical partnerships and collaborations with clinicians. The genesis of the relationship between CINJ and Princeton began in 2009, with the recognition that there were quite a few science collaborations already happening between investigators at both institutions.
That organic collaboration grew into an MOU to begin working in a more formal way together, and then, finally, a request to the NCI during the redesignation in 2012 to formally add Princeton as a consortium partner with the Cancer Institute of New Jersey.
As you know, that process requires the NCI to review—that is both at a site visit and at the parent committee—the application and the justification for the formation of the consortium.
The approval from the NCI actually comes to the designated cancer center, so the designated cancer center essentially has to demonstrate that the addition of this partner is going to be value-added or enabling for the mission, vision, and focus of that cancer center.
So, in our case with Princeton, it was clearly the case that there was collaborative and impactful science being performed. The expansion of certain shared resources, and our proximity, I think, is critically important.
I think these relationships are built on the ability for the consortium partners to interact with each other on a regular basis and having them be robust members of the cancer institute, so it’s not just simply, we’re a part of your consortium, but we’re actually interacting, and so, at the moment, we have 21 Princeton faculty that are actively a part of our consortium cancer institute.
To be considered for approval to include a consortium partner, the designated center must first meet certain minimum requirements. The potential partner must demonstrate at least five independently-funded investigators and seven independently-funded projects at the peer reviewed R01 equivalent funding level.
With respect to Princeton, we currently have 14 independently-funded Princeton faculty members and 25 independently-funded projects at Princeton. Princeton is a very robust contributor to our NCI-designated center.
Meeting those minimum requirements, though, is not in and of itself sufficient. It is critically important to demonstrate that the partners are interacting as a true center. For us, Princeton faculty are involved across our research programs that define our CCSG. Currently, we have five programs and 14 shared resources. Princeton faculty are active members of these programs, and leaders of shared resources. This type of robust engagement requires the close interactions facilitated by our proximity to one another.
We coordinate these interactions through the efforts of an associate director for consortia research, a Princeton faculty member, who sits on my research leadership team as an associate director.
We have successfully integrated Princeton faculty into the day-to-day operations, leadership and science of the cancer institute.
I believe you’re right that there are many examples of consortia partnerships that exist right now, and, certainly, I think more opportunities will present themselves in the future for groups to look at potential partners, who, as I said, may not have the breadth and depth to become an independently designated NCI center, but would bring incredible value to an NCI center with a similar focus and mission for the region that they serve.
You grew up, of course, in the NCI, in Steve Rosenberg’s shop, so I guess we should talk about immunotherapy.
Absolutely. So, some of my fondest memories are the time I spent in the Surgery Branch.
I can tell you one of the things that is most satisfying to me is having watched Steve be so focused in this area for the years that I was there and since, to finally see cancer immunology and immunotherapy be recognized as truly that fourth approach to treating cancer, beyond surgery, radiation and chemotherapy, to truly have it stand as a fourth pillar of our strategies for understanding cancer and then treating cancer.
I think it’s incredibly rewarding, and I’m sure he must have tremendous pride being one of the forefathers of the field and a driving force in advancing this strategy.
It certainly is a major area of focus for us at the cancer institute, and was before I arrived. There are a number of investigators, who had a history of being focused on the tumor microenvironment, on immune response to tumors, on leveraging strategies to harness and enhance the immune response against cancer.
And so, we have a strong basic, translational, and clinical science program. We conduct immunotherapy trials, both investigator-initiated and in cooperation with pharmaceutical companies. We provide CAR T-cell therapy here. We have our own cGMP facility.
We are gearing up through partnerships to have our own vector production and cell transduction facility within our cGMP facility, to be able to produce clinical grade material for early phase trials to drive our phase I program and beyond.
We have a particular expertise in cancer metabolism that is the result of a strong collaboration between scientists at Rutgers and Princeton under the leadership of Eileen White and Josh Rabinowitz.
We’re focusing now and we’re soon going to be launching a center of excellence focused on cancer metabolism and cancer immunology because we believe that an understanding of the tumor and immune microenvironment and the metabolism of immune cells is critical to better leveraging immune responses against cancer.
I know that cancer immunology is a focus at many cancer centers across the country. Here at CINJ, we’re leveraging some of our unique strengths in cancer metabolism and immunology with the goal of developing a better understanding of biology in order to develop more effective immunotherapy strategies for treating cancer.
So, yes. Steve Rosenberg rubbed off on me, at least with respect to the importance of this area of focus, and the importance of a focused approach. My goal is to surround myself with the smartest cancer immunologists, so we can make progress.
Is there such a thing as an immunotherapy divide now? Between the haves and the have nots?
You know, I hate to think that that’s the case. There are certainly economic realities around cancer care in general, and significant disparities that exist in access to care.
I don’t think this is unique to immunotherapy. You can say the same for some of the more expensive targeted therapies, or antibody based therapies, whether those antibodies are directed against immune modulating targets or other receptors or targets.
I think it’s a major challenge for all of us in the field to really leverage our cancer prevention and control programs and our community outreach and engagement programs to identify where these barriers to access may exist and try to lower those barriers, especially with respect to socioeconomic barriers. The cost of cancer therapies is becoming prohibitive. And I think we as cancer centers and cancer center leadership need to be voices addressing lowering these costs and improving access. That is certainly a major focus of ours.
We work very hard in partnership with the patients, our financial counselors, insurance providers, and the health system, in order to relieve some of these burdens in order to provide the best therapy for our patients.
I acknowledge, this is a problem universally, beyond just the area we serve, and it’s something that we have to tackle.
Can we talk about population size and maybe even together with outreach and engagement, because one drives the other?
With a diverse population of nearly nine million in our state, cancer prevention and control is critical. It is an integral component of our mission, and we see it as a responsibility for us to engage in research that will result in impactful solutions to reduce New Jersey’s cancer burden. Our Cancer Prevention and Control Program is a real jewel within our CCSG.
For example, our program focuses efforts on tobacco control, which has resulted in positive changes to tobacco regulation policy.
Helping both at the state and national levels, some of this guidance has been geared toward regulating flavors or colored packaging or other elements that might attract people to begin smoking, especially around small cigars that have been skirting the rules for cigarettes in terms of flavor additives and colored packaging. Our program and our experts have been instrumental in providing policy guidance surrounding that topic.
A lot of work focuses on e-cigarettes here, both better understanding the potential benefits of e-cigarettes in transitioning current smokers of combustibles off of combustibles, and recognizing the dangers of e-cigarettes as an entry way, especially for youth and new smokers.
We are recognizing significant risks, and are focused on eliminating what is a danger, I believe, in vaping and e-cigarettes. We are studying these risks and evaluating them against any potential benefits with respect to weaning current smokers off of combustibles. We have a major effort in focused on sun exposure and understanding melanoma risk. We have a high incidence of melanoma in the state.
Researchers in our CPC program have focused studies on the dangers of indoor tanning, as well as education around safe sun exposure on the beaches of the Jersey Shore during the summer.
We also focus on risks unique to populations within New Jersey. For instance, understanding the role of dyes and hair relaxants for African American women with respect to breast cancer risk, as well as a major focus on unique East Asian populations that exist in New Jersey and their cancer risk.
As a state, New Jersey is actually the fifth in cancer incidence overall in the United States, and therefore cancer screening, prevention, and education is of critical importance. One of the programs I’m most proud of is called ScreenNJ, which is a partnership with the State Department of Health. We have a number of partnerships with the New Jersey State Department of Health, including the co-management of the state’s cancer registry.
ScreenNJ is an initiative we started when I arrived in 2017, to identify and address the highest-incident cancers in the state. Not surprisingly for us, it was lung and colon, and we began to focus efforts and expand partnerships across all the health systems and other academic institutions in the state, to draw a bullseye around colon and lung cancer.
We believe that if we can effectively deploy a statewide screening, prevention, and education program, and have an impact on those two cancers, we can address the fact that New Jersey is fifth in cancer incidence and begin to reduce those numbers.
When we began ScreenNJ in 2017, we were in three of New Jersey’s 21 counties with about 20 sites. We are now in 17 of New Jersey’s 21 counties at 87 sites spanning most of the state.
This is an example of the impact we’re having in our catchment area, through the creation of strategic partnerships.
We receive state funding that we manage specifically for this program, and we deploy those funds to institutions, including Federally Qualified Health Centers across the state, to improve access to screening for lung and colon cancer, as well as for education and prevention purposes. As part of this, the program navigates patients who may have positive findings to care delivery sites, where they can have suspicious lesions managed or cancers that have been diagnosed effectively treated.
I believe ScreenNJ will be a platform for us to expand into other cancer types. We have a big initiative around HPV-related cancers, some legislation working its way through the state of New Jersey to make it easier for folks to get vaccinated for HPV.
Focusing on the specific needs of our community is critically important to us. ScreenNJ is just one example of the programs that hopefully will have a positive impact.
That’s really all fascinating. Is there anything we’ve missed?
It’s an exciting time in our field in general and for the growth and advances we continue to see in New Jersey. We are fortunate to have implemented a research mechanism and care delivery model that brings together talent from the academic sphere and the health care delivery sphere into a unified team to approach what is a significant problem in our state.
Further addressing that challenge here will come in the form of a physical manifestation. With the support of RWJBarnabas Health, we’re about to break ground on a brand new cancer building right here in New Brunswick.
The new structure will be attached to our current facility and will more than double, in fact, close to triple, our current space in terms of square feet for both research and clinical care delivery.
It’s a very positive direction in which we’re heading, and Paul, I appreciate the opportunity to talk about it.
Thank you very much.