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You know you're supposed to do a breast self-exam. But what do you do when you think you've found something troubling? Medical oncologist Megan Kruse, MD, explains normal and abnormal lumps, bras and breast cancer risk & more. 

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Lumps, Skin Changes and Other Breast Cancer Concerns with Dr. Megan Kruse

Podcast Transcript

Nada Youssef : Hi. Thank you for joining us. I'm your host, Nada Youssef, and today we have Dr. Megan Kruse, medical oncologist here at Cleveland Clinic. Today we're taking your questions regarding breast cancer. So make sure to send us all your questions in the comments section below so we can answer them live. Before we get started, please remember this is for informational purposes only and not intended to replace your own physician's advice. Thank you so much for coming today.

Dr. Megan Kruse: Thank you for having me.

Nada Youssef : Well, do you want to go ahead and start by introducing yourself to everyone?

Dr. Megan Kruse : Sure. I'm Megan Kruse. I'm one of the medical oncologists here at Cleveland Clinic. I'm a specialist in breast cancer. I do the medical therapies that go along with breast cancer: chemotherapy and anti-estrogen therapy. And I also do some clinical research in breast cancer treatment.

Nada Youssef : Great. Thank you. Well, I want to kind of start with a general question.

Dr. Megan Kruse : Sure.

Nada Youssef : When it comes to breast cancer, are there certain symptoms that we're supposed to be looking for?

Dr. Megan Kruse : Yes. I think that any general change in your breasts is a symptom that you should report to your doctor. Thinks like lumps that you haven't noticed before, skin changes, particularly redness of the breast or dimpling of the breast and then nipple changes. If there's nipple discharge or bleeding or changes in the shape, those are things that we as physicians really want to hear about.

Nada Youssef : Okay. And then speaking of lumps, is there a normal lump versus an abnormal lump?

Dr. Megan Kruse : There are. And that's what's really challenging about this is that depending on a woman's age and their menstrual history, also their pregnancy history, lumps can mean different things. And so it's really important to, if you find a lump, talk to your doctor about it so that we can decide if there's additional imaging that you might need to figure out if it's a concern or not. Or whether you need a biopsy. Not all lumps mean cancer but we definitely want to know about them and evaluate them appropriately.

Nada Youssef : Great. Okay, well we have our first question from Jen, "Can wearing a bra all the time cause breast cancer? I sometimes sleep in my bra."

Dr. Megan Kruse : That's a really great question, Jen. I know a lot women worry about this and feel more comfortable in their bras. And truthfully, I think sleeping in your bra or wearing a bra a lot of the time is actually quite safe. This is not something that we counsel our breast cancer patients or women that we see to do any differently.

Nada Youssef : Okay.

Dr. Megan Kruse : I would feel comfortable with you going ahead and doing what's most comfortable for you.

Nada Youssef : Great. Thank you. And then we have Nicki, "How often should I be doing a self-exam? Should this be done during my daily shower?"

Dr. Megan Kruse : Breast self-exams are really, really important. They're something that we've changed our recommendations on over time. But now the recommendations are that women are familiar with their breasts. So we generally say examining your breasts at least once a month is important. Often, around the time of your menstrual cycle and then the shower's a great place to do it because you have access to your whole breast and you can find out what it different or changing. Breast self-awareness is the most important thing.

Nada Youssef : Great. Thank you. And then we have Mikaela, "My daughter has had leaking from her breast for a year. First ultrasound found no mass. This recently turned into bleeding. And another ultrasound also found no mass. I needle biopsy returned benign. Is this something not to worry about? She's 24 years old."

Dr. Megan Kruse : So Mikaela, this is a really important question and as you can see, just like we were talking about with lumps earlier, all lumps need evaluation. Having these couple ultrasounds was important. The benign biopsy is quite reassuring. Although we always worry about changes in nipple discharge and general changes in the breast. If there is something that's changing, I would encourage your daughter to reach back out to her doctors that have done the evaluation so far to get a sense of if there's anything more to be worried about. Both her gynecologist or breast physician or even a general internist could help with this kind of complaint. It's probably something that we don't have to worry about but should be evaluated just to make sure.

Nada Youssef : Good to know. Thank you. And jumping on Alice, "Can the chemicals in my deodorant cause breast cancer?"

Dr. Megan Kruse : I've heard this question many times actually. And I think we all want to get rid of things that could cause cancer. It's very, very reasonable to worry about chemicals. I have not seen any data or heard anything that specific deodorant containing chemicals are concerning for causing breast cancer. It's not a routine recommendation that I make to my patients to stop using deodorant once they've had a breast cancer. I think you can safely go ahead and use it.

Nada Youssef : Okay. Great. Very good question. And then I have Jamie, "What would your advice be to someone who has had the genetic testing and has been found to have a CHEK2 and PALB2 mutation along with a strong family history on maternal side of breast cancer? I'm getting conflicting advice from my OBGYN, family doctor and genetic counselor.

Dr. Megan Kruse : This is also a very important question. These two genes are genes that, until very recently we weren't absolutely certain that they were involved in breast cancer risk. But now we know both CHEK2 and PALB2 are very important and do increase a woman's risk of breast cancer. Certainly, Jamie, your breast cancer screening should be more intense than other women who don't have these genetic mutations. The way that that's actually done is different for each person. Usually it depends on your age, if you've had a cancer already, and the age at which your family members may have developed their cancers. And this is something that I think maybe having your doctors talk together to decide on the best way to do it would be the best approach. Usually, and I'm sorry I don't know your age, but usually a combination of mammogram and breast MRI can be helpful in this situation. But again, that depends a little bit on your age. Keep talking with your doctors, but definitely get screened. And you're somebody who I would really encourage be aware of your breasts and be doing breast exams at home.

Nada Youssef : Great. Thank you. Thank you Jamie for that question. Jumping on to Gina, "What are risk factors for getting breast cancer?"

Dr. Megan Kruse : That is a very, very important question. I guess applicable to all of us here, both sitting here and in our audience at home.

Nada Youssef : Sure.

Dr. Megan Kruse : Risk factors for breast cancer, the biggest risk factors are being a woman and aging. The older you are, the more likely you are to develop a breast cancer. Other risk factors that we can control include alcohol use. We would like women to stick the recommended limits of alcohol within a week. Generally that's seven alcoholic drinks within a week or one a day. One of the biggest risk factors that's getting more attention now is actually weight and obesity. And we know that being overweight can actually increase your risk of breast cancer by 20%, some reports even 40%.

Nada Youssef : Wow.

Dr. Megan Kruse : And so having a healthy diet, maintaining exercise, doing all that you can to keep your weight down is actually really, really important.

Nada Youssef : Now one of the factors you said was women, being a woman. Is ... What is it for a man? I know men can also get breast cancer. Women have higher chances, can you explain why?

Dr. Megan Kruse : Sure. A lot of that has to do with hormones. Many of the breast cancers that we detect are hormone driven cancers. And so for over a woman's lifetime, they're exposed to hormones for a longer period of time, which is why this is more common in older women. Men don't have as much estrogen or progesterone in their body as women do and therefore don't necessarily get as many breast cancers as women do. Also the sheer volume of breast tissue. Men have some breast tissue but not as much as women do. That tends to be why women get more breast cancer than men.

Nada Youssef : And are the symptoms the same for men as they are for women then?

Dr. Megan Kruse : Mm-hmm (affirmative).

Nada Youssef : Lumps and changes in the breasts.

Dr. Megan Kruse : Yes.

Nada Youssef : Okay.

Dr. Megan Kruse : Yes, generally the symptoms are the same. Because men have less breast tissue, they may not notice obvious skin changes. But for men, lumps in the breast are a pretty common presenting symptom of having a breast cancer.

Nada Youssef : Okay. Very good to know. Thank you. Let's see. I have Dina, "Both of my breasts are almost always sore. It does get worse around my menstrual period but the soreness never really goes away. Should I be worried?"

Dr. Megan Kruse : Dina, this is also a great question. I think a lot of women have breast symptoms that sort of come and go but never entirely go away. Usually that's actually pretty common and not something to be worried about, particularly if they're changing over the course of the month. We do worry about pain that increases and then sort of never comes down from that peak point. Pain that is sort of same month to month for you, even if it never goes away, is generally not a problem. But of course something that we want to make sure you talk to your doctor about.

Nada Youssef :  Okay. Great. Thank you. And then we have Melanie, "How reliable is the BRACA test? My mom had that done since she had breast cancer and then it went to her brain."

Dr. Megan Kruse : I'm sorry to hear that. It's always a worrisome situation and a tough situation when cancer spreads to the brain. I hope she's doing okay. Our BRACA testing is actually really good. Right now, the test is actually better than it was say five years ago or even 10 years ago. The tests are improving over time. For patients who are diagnosed with their breast cancer many years ago, we often advocate that they get their genetic testing, either repeating or updated. And many of the genetic testing companies keep the results on file for years and check back in for new changes and new developments when they come about. Even when we know that the BRACA testing is reliable, unfortunately knowing that information doesn't always prevent the cancer from spreading or from us being able to give treatments that prevent the cancer from spreading. But the test itself is very good and reliable in getting a positive result.

Nada Youssef : Good. Good to know. Okay. And then I have Stephanie, "When should I get my first mammogram? I'm 30 years old."

Dr. Megan Kruse : Mammogram recommendations seem to be changing all the time. And this is probably why there's a lot of confusion about this. And I'm glad that Stephanie brought this up during our time together. We recommend as a cancer community that you start talking to your doctor about mammograms if you have no family history around the age of 40. And our national guidelines really suggest that between the age of 40 and 49, a woman has the choice to get a mammogram or not. By the age of 50 we do recommend that all women are getting an annual mammogram. There are some guidelines out there that suggest that mammograms could be done every year or every other year. And again, that's a very personalized decision based on your own risk factors, your own family history. It really should be talked about with your doctor. But if you're motivated to get a mammogram around the age of 40, definitely let your doctors know. And by the age of 50 it's something that, if your doctor hasn't brought up, you should absolutely bring up with them.

Nada Youssef : Great. And while Delores is 83 years old, she's told that she doesn't mammograms anymore. Is that true?

Dr. Megan Kruse : It depends. Delores, it sounds like you might want your mammogram and hopefully your health is really good. Our recommendations for when to stop mammograms are also highly variable. A lot of our national societies say around the age of 75, it's reasonable to consider stopping.

Nada Youssef : Okay.

Dr. Megan Kruse : Now it has a lot to do with your other medical problem. And if your life expectancy is 10 years or more, and you don't have a lot of medical problems, say with your heart or with diabetes, it's reasonable to continue past the age 75 if that's something you'd really like to do. I usually recommend only continuing in women who say that they would get breast cancer therapy if needed.

Nada Youssef : Okay.

Dr. Megan Kruse : If a surgery or radiation were recommended that you would have to know that if a cancer is found that those therapies might come along with it. And you didn't think that you'd want surgery for something that was found than maybe that's a time to stop considering mammograms. But, if you're healthy and active and in your 80s, you can definitely stick with them.

Nada Youssef : Alright. Thank you. And then we have Shawna, "Are lymph nodes that show up on a mammogram really nothing to worry about?"

Dr. Megan Kruse : That's a great question and it's something that we struggle with. Lymph nodes can pop up on mammograms and on breast ultrasounds and depending on the characteristics of that lymph node on the imaging study, based on what our radiologists tell us, we can get a sense if the lymph node is concerning or not. Any lymph nodes that are concerning generally get biopsied. But there are particular features of lymph nodes on ultrasound or mammogram that can help us to know if they're concerning or not.

Nada Youssef : Okay.

Dr. Megan Kruse : It is sometimes possible to find a lymph node on an imaging study and really not be that concerned about it.

Nada Youssef : Great. And then I have Janie, "What are margins in relation to breast cancer?"

Dr. Megan Kruse : Margins are something that I pay attention very carefully on pathology reports for my women who have had a surgery for breast cancer. And basically what they are, are edges around the breast cancer that your surgeon takes out at the time of the operation that are free of cancer. You can imagine it sort of like an orange. That the cancer would be the inside part of the orange and the margin would be the rind around the orange. What we always go for is sort that rind of normal breast tissue around the cancer to make sure that no cancer was left behind. That's really our goal. What we, as medical oncologists, like to see at the end of the surgery is negative or clear margins, meaning no cancer at the edges of the specimen that was taken out at your surgery.

Nada Youssef : Okay. Makes sense. Very good to know. And we have Sandy, "Can physical activity reduce the risk of breast cancer?"

Dr. Megan Kruse : Yes, absolutely it can. And probably in ways that we're not entirely certain of quite yet. But we know that exercise and activity decreases your weight potentially and keeps your heart in better shape and prevents other major medical problems, like diabetes in many ways. And as weight is a risk factor for breast cancer and inactivity, we think that being up and being active and exercising is really, really good thing.

Nada Youssef : Okay.

Dr. Megan Kruse : We recommend that our ladies get at least 30 minutes of activity, at least five days a week in order to decrease their breast cancer chances.

Nada Youssef : Okay. Great. And then piggybacking off of that, does smoking give you a higher risk for breast cancer?

Dr. Megan Kruse:  Smoking can increase your risk for many cancers, not specifically for breast cancer.

Nada Youssef : Okay.

Dr. Megan Kruse : But we do worry that ladies who smoke have a higher chance of lung cancers, cancers of the head and neck or in the mouth. And also, higher risk of heart disease. If you had any of those things, it may it harder to treat a breast cancer that comes about. Although it may not be directly related to breast cancer, we really love when women are able to quit smoking.

Nada Youssef : Sure. Definitely. And then we have Marlene, "How does my menstrual and reproductive history affect my risk?"

Dr. Megan Kruse : That's an excellent question. Menstrual and reproductive history has a lot to do with a woman's lifetime exposure to estrogen and progesterone. As we mentioned, having those hormones around during your lifecycle increases your risk of a hormone sensitive breast cancer from happening. We do know that ladies who get their periods early and potentially go through menopause later have a longer period of their life where they're exposed to hormones and therefore have a higher risk of breast cancer. Women who have had pregnancies before are actually at a lower risk of breast cancer. And that may be a little counterintuitive but actually when you're pregnant, although you have higher estrogen levels overall, those hormones are actually more balanced. It's not that you have estrogen by itself in your blood. Women who have had more pregnancies or women who had their first pregnancy at a younger age actually have a lower risk of breast cancer.

Nada Youssef : Very interesting. Great. And I have Joanie, "At 56, I had DCIS Stage One, when will my growth be checked? So far they have been denied checkups."

Dr. Megan Kruse : DCIS is actually a kind of confusing topic within breast cancer. It's sort of a pre-cancerous lesion that is treated like a cancer with things like surgery and radiation and even in the medical therapies that I offer. It can be challenging because it's certainly an increased risk factor for breast cancer but not necessarily a cancer on its own. It does mean that your girls should be checked earlier than they may otherwise have been. I don't know how old they are now. Certainly the general mammogram recommendations apply. It's something that I would think about them getting mammograms starting younger, on the younger end of the range, like 40 that we talked about. Maybe even younger than that. I think Joanie, you said you were 56 when you were diagnosed, so 40 would actually be a decent age for any of your girls to start with their imaging. That being said, they should be doing breast self-exams and having breast exams with their doctors even before the age of 40.

Nada Youssef : Okay. And we Audrey, "Is there any research that shows that stress impacts breast cancer?"

Dr. Megan Kruse : This is a question that's sort of like the activity question where we all believe that increased activity is better for your cancer risk. Decreased stress is clearly for your cancer risk, but we have a hard time showing that in studies. And it's oftentimes because figuring out how much stress we all go through on a daily basis is a tough thing to monitor. Anything that you can do to decrease your stress level improves your general health. Whether it has an impact on your breast cancer risk, I can't say for sure but it generally is much, much better for your health.

Nada Youssef : Okay. And how about when it comes to diet? I always speak to different physicians in these broadcasts and I know diets usually has a link straight with the disease. But is there a certain diet that we should be following to prevent breast cancer?

Dr. Megan Kruse : Really just a general heart healthy diet is what we recommend. That is really what's best for your overall health. And it's been shown to be good for our cancer survivors. It's what we recommend for those who are looking to even decrease their chances of breast cancer before it happens. Apart from that, we don't have other specific diet strategies that have been shown to decrease the chance of breast cancer.

Nada Youssef : Okay. Great. The next question, we have Cassandra, "Is there any link between birth control and breast cancer?"

Dr. Megan Kruse : That's a really, really great and important question.

Nada Youssef : Sure.

Dr. Megan Kruse : And it's one that our medical community has gone back and forth with for many years. As of right now, we don't say that there is a clear link between birth control use and breast cancer. It's something that we track for all of our ladies who have breast cancer and certainly we may change the method birth control after a breast cancer has been diagnosed, especially if a cancer is diagnosed that's hormone sensitive. In that situation we tend to stop birth controls that are hormone based. But strictly taking birth control over the course of your life should not really impact your risk of breast cancer.

Nada Youssef : Okay. And then Amber, "I have a lump. Should I be worried about it?"

Dr. Megan Kruse : Definitely. As we talked about before, any lump in the breast is something that should be evaluated to make sure that it's not cancer. There are many lumps that can be nothing. And then there are lumps that are very serious and they're always hard to know until you're actually in the office with a doctor examining your breast. I would encourage you to reach out to your physician and get in to get checked. And then your doctor will order whatever imaging is appropriate to figure out what's going on.

Nada Youssef : If we have someone, let's say like earlier, someone 30s, 35, and they just started self examining, and they do feel some lumps. Does it have to be painful? Does it have to be really big? Or, do we just kind of check the consistency of the next we check and the next time we check and see if there's any new ones or any that disappear?

Dr. Megan Kruse : Absolutely. Yeah. Actually any lump can be concerning. It doesn't have to be painful.

Nada Youssef : Okay. That's yeah.

Dr. Megan Kruse : It doesn't have to be big.

Nada Youssef : Okay.

Dr. Megan Kruse : It's hard to know with all of us at home saying "I have this lump. Should I see my doctor or not?" Your default answer should always be "Yes". At least have your doctor check it out to let us figure out what is concerning and not. If you have lump and then it doesn't go away but it's been evaluated, it's not necessarily a point for concern, as long as somebody's following that. There are lumps in the breast in young women that are very, very common and can actually change with their menstrual cycle or with your caffeine intake. And these are things that your doctor will often consult you about. Once a lump has been evaluated then your doctor will be monitoring to make sure that it stays similar or even goes down in size or that no new ones develop.

Nada Youssef : What is the link between caffeine and the lump size?

Dr. Megan Kruse : You can actually have changes in lumps in the breast, things that are responsive to caffeine. For women who has fibrocystic changes, we often recommend decreasing your caffeine intake if you're able as a way to decrease the lumpiness of your breast and give you some peace of mind that there's nothing concerning going on.

Nada Youssef : Okay. So if it's questionable, go see a doctor.

Dr. Megan Kruse : Absolutely. If you have any question about a lump, go see your doctor.

Nada Youssef : Okay. "Can benign cysts become cancerous?"

Dr. Megan Kruse : Generally not. Benign cysts really have a particular appearance on breast imaging. We often feel very, very comfortable that a cyst is truly a cyst and nothing more.

Nada Youssef : Okay.

Dr. Megan Kruse : Cysts can very easily, many times in the office, be what we call aspirated or have the fluid inside a cyst be drained out. That can be a good test because that fluid can be sent off to look for signs of cancer. It's often reassuring for a woman to know that there were no signs of cancer there.

Nada Youssef : Sure.

Dr. Megan Kruse : But a cyst really looks very different on imaging, even though it might not feel different than any other kind of cancerous lump on your body. Another reason that it's important to see your doctor.

Nada Youssef : Okay. Great. And then Nancy, "should everyone be screened for BRCA1 and BRCA2?"

Dr. Megan Kruse : We talk a lot about BRCA1 and BRCA2 as the main genes that can have mutations that lead to inherited breast and ovarian cancer syndromes. We actually have really good guidelines for which women are at risk for having those gene mutations and who should be screened for them. We talk about women who have their diagnosis under the age of 50 as being those who are definitely at risk for having these mutations and should absolutely get testing. There are certain types of breast cancer where even up to the age of 60 we recommend having the testing done.

Nada Youssef : Okay.

Dr. Megan Kruse : And then depending on your family history, if you've had breast cancers in certain family members, ovarian cancer in certain family members, or even other cancers that may go along with these inherited breast cancer syndromes, that may raise flags for your doctor to order genetic testing. There are also particular groups of women, ethnic groups of women that we recommend testing like Ashkenazi Jewish women. The whole population of women does not need to be tested. Even the whole population of women with breast cancer doesn't need to be tested. But if you have particular features of your history, of your cancer, then we will recommend genetic testing.

Nada Youssef : Okay. Great. And then I have Stacy, "Are mammograms painful?"

Dr. Megan Kruse : Many ladies tell me that mammograms are not a fun experience.

Nada Youssef : Okay.

Dr. Megan Kruse : To get really good views of your breasts and any lumps that might be in the breasts, mammograms can cause some discomfort and cause some pressure on the breasts.

Nada Youssef : Okay.

Dr. Megan Kruse :  We'd like to think that it is nothing that is more uncomfortable than having a breast cancer diagnosis and all the treatments that go along with it. We really think it is worthwhile. Typically any discomfort you have associated with a mammogram will go away once the mammogram is over. It's just related to the type of pressure that your radiologist will need to get the types of images and views that they need to make sure that there's not a cancer in there. I can't promise you that it'll be a comfortable experience-

Nada Youssef : But it's worth it.

Dr. Megan Kruse : But it's worth it. And hopefully it's a short-term discomfort.

Nada Youssef : Good. Good. Alright, and I have Jenny, "Are there other types of cancers that I can get because I have breast cancer?"

Dr. Megan Kruse : Generally not. If you have a breast cancer that's not related to one of these genetic mutations, you should really not be at risk for any other particular cancer. Now that being said, there are women who get breast cancer because they've had radiation before. Women who say have a history of lymphoma and those women may actually be at a higher risk of both breast cancer and other cancers like lung cancer. If you have a particular genetic mutation, there's often sort of a group of cancers that you're at risk for and once the genetic mutation is known, your doctors will help you figure out what other testing you need.

Nada Youssef : Okay.

Dr. Megan Kruse : Whether it's more frequent colonoscopies or other imaging or just more frequent physician visits. Simply having a breast cancer should not increase your risk for any cancer but you want to make sure that your current breast cancer is not linked to something else-

Nada Youssef : Sure.

Dr. Megan Kruse : Which should make us concerned.

Nada Youssef : Sure. Okay, I have time for one last question here. I have from Danielle, "Do we have any breast cancer support groups here at Cleveland Clinic?"

Dr. Megan Kruse : We do. We actually wonderful breast cancer support groups.

Nada Youssef : Great.

Dr. Megan Kruse : Driven mainly by our fantastic group of social workers. And I have to say that working here, that's one of my favorite things is being in such a team-

Nada Youssef : Right.

Dr. Megan Kruse : That cares for breast cancer patients. We have a support group run by one of our social workers that meets on a regular basis to talk about all the issues that surround breast cancer. Whether that's your diagnosis, your treatment and living your life after a diagnosis of breast cancer. And these are issues that we focus so much on treatment that we don't always talk about what happens after.

Nada Youssef : Sure.

Dr. Megan Kruse : But really, really important issues in terms of child bearing, working, future health, sexuality. And these are things that our support groups are wonderful at tackling. If you're here in the Cleveland area-

Nada Youssef : Right. I was just going to ask that.

Dr. Megan Kruse : And have access to our particular support groups, groups like this exist throughout the United States. There are many great organizations that are involved in this and also really good online resources. The common resources we direct women to: The National Institutes of Health and the National Cancer Institute have great survivorship resources on their website. And of course, an institution or group that we're all familiar with, The Coleman Foundation has lots of important information on their website and often have local offices that can connect you with the support groups in your area.

Nada Youssef : Sure. Sure. Thank you so much for wrapping up Breast Cancer Awareness Month with us here. But before we let you go, is there anything you want to tell our viewers.

Dr. Megan Kruse : Yeah, absolutely. I'm sorry that we're talking in the first few days of November and not during October. But I would like to think that breast cancer awareness is not something that should be limited to October.

Dr. Megan Kruse : I think it's great if you time your mammograms with October so you remember but truthfully the most important thing I can say is know your breasts and get your mammogram. I see ladies every day who had their breast cancers diagnosed early. They may not have been found at all if it weren't for their mammogram. And thankfully those are women who are success stories.

Nada Youssef : Right.

Dr. Megan Kruse : I would love for all women to get their mammograms.

Nada Youssef : Thank you. Thank you so much.

Dr. Megan Kruse : Absolutely.

Nada Youssef : And that's all the time that we have for today. But for more health tips and information, make sure you follow us on Facebook, Twitter, Instagram, and Snapchat at clevelandclinic, just one word, and make sure to join us next Thursday as we take your live questions regarding back pain with Dr. Robert Bolash. Make sure you guys tune in. And thank you again for watching.

Dr. Megan Kruse : Thank you.

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