Everybody forced to open 22 23 Donner's basketball team all 20 box case number four Results are right there. Let's go ahead and get started. Good luck everybody All right, let's do it. What do you got red and yellows in this? Red touch yellow killer fellow Well, we'll see I'm gonna Well, I can't just like hook it because you're there so I have to like I can just give it an extra slap Sure slap. Yeah, I could just pass the box to you. That's true. You're good. That's a good idea Watch this security cameras be pretty fun Yeah, exactly All right guy red and yellow miles Turner and Devonte Graham Keegan base Yeah, dude, 2021 built for October Trevor Kiehl's rated rookie number to 25 for the Knicks ready yellow Keegan Murray Kings Red and yellow Michael Porter jr. Nuggets Narkich Blazers They're all around yellows. Yeah, crazy Christian Brown rated rookie red and yellow auto nuggets. Nice hit Nice No, it's written yellow the soon to bulls Jalen Green Rockets Topps related question. I mean, I guess it depends on what it is, but sure I don't work for tops But I can answer you what would I know because I work here. I don't know Cameron Thomas If they offered me enough money, you know, it's a bonus Keegan Murray Kessler red and yellow buddy heel Jalen during pistons rated rookie Houston Red and yellow Gordon nugs Lyle's Kings Got a Kyle Larry 1 of 25 for the heat Red and yellow Terence man Clippers That's even more difficult So FYI guys vet bases split even you'll get all your rookies in red yellows all the parallels all that good stuff All right, got it sort and ship. I gotta gotta gotta gotta gotta gotta gotta gotta got it Who does Matt Lancer? What's the character Matt Lancer plays? It's definitely worth something. It's a one-of-one auto from Star Wars Slight blue to 25 McDermott for the Renyo, yeah, I'm going this stack right here So I'll do okay right here top load sword. That's oh Matt Lane. Oh the animating Anakin Skywalker. Yes, that's worth a good That's worth a good bit. You should be able to find some comms on eBay for his autos Red and yellow Suggs Josh Christopher Yeah, that's where that's probably worth a good bit Not as much as a Hayden, but yeah Lot of animated fans be collecting cards, dude Van Vliet, Kennedy Chandler rated rookie red and yellow Red and yellow Rosier Hornets. Yeah, I heard her for the Kings J. Dub You Should be able to find if you go on eBay and search like sold listings you should be able to find some sales of his auto Yeah, that's a great card man Number two one. Oh, okay. The Martin red and yellow ready to rookie Mowgli calves No, I did wrong stack Topping Yeah, man, this is so difficult Yeah, ripping and opening cards running basic. It has that addictiveness to it Middleton Josh Hart's like collecting really anything You get stuff. You just want more Kylo, yeah, he wanted they wanted he wanted to shoot more. Yeah, he did Oh, it's T. Wolves dealing Terry bulls.  You see I'm doing now Yeah, Donnie does good impression Star Wars breaks Sub Jason the chrome is falling apart Red and yellow Lamello red in the yellow Lamella late yellow mellow yellow Chris Paul Bajie. There's an IV Gun fever. What is that? Nemard rated rookie to 25 pacers Kind of a Mitchell. Oh, oh, sorry Donovan. Sorry Donovan. Joe Harris. There's a Walker Kessler rated rookie red and yellow jazz Matherin bancaro red and Lamello yellow Jalen Williams thunder rated rookie auto number two ten two of ten. Nice Thunder Red and yellow McConnell red and yellow Shengyun This is a lot of boxes Um the flagship probably not but galaxy. Yeah. Yeah, for sure. What we doing galaxy on release I don't know uh derosin. I'll top my head. Yeah, we talked about two three weeks Uh derosin and kaminga actually I think it ended the month like the very end of the month Nice Roddy monotary, which I guess is three plus weeks. Not bad. Not bad. Not bad. All adipo and a more junior rated rookie Bajie ivy Come on six. Oh nice during the 25 During to 25 pistons. What are the Yankees all about october and this millennia paul george red and yellow Can't beat the ashros Red and yellow tre got zion Matherin Paolo Yeah, this is 2021 this 2021 shirt. We're gonna keep ragging on before it. I got this from Blake. All right. Blake gave me this Got it from a red socks project. Yeah red socks beat themselves too Just right now regular season because I don't know man middleton mcdermot Edwards and dylan terry rated rookies chet homegren It is the Orioles division this year Okoro heart uzman jang It's a sharp Colanthony russell westbrook Oh, jeez six. Yeah, that sounds like a pain Yeah, yeah, man. That's thanks. I'm sorry What timing, huh got mcconnell jjj Armani brooks drummins What's up, donnie? I don't I don't know Come on donnie. What's breaking? What's breaking that has spots left? I'm working on it He's your washington kenneth lofton jr. Raider rookie for the grizzlies on the red and yellow God Ivy Well, there you go six. I guess it was worth it Light blue gary trend jr. Raptors are 25 Red and yellow harrison barns matherin Ben caro Yeah, six collect houses Everybody played that game a couple years or all the all the big uh Air bnb played the game two years ago and screwed us all over Not air bnb themselves. So you know what I mean Marcus smart red and yellow dice daniel's ready to work you for the pelicans Uh, anyone it's uh, I just scheduled to start time. It's all run it So here's a break schedule link be like 1140 easter 1145 eastern Always break by schedule here Uh, red and yellow halla burton. You got markin in Yeah, collect houses six. That's what you got to do You'll get Kevin ported jr. I don't if you uh collect different monopoly games Red rookie hardy red and yellow for the Mavericks losing that game Losing all the games. Yeah, it should adjust to your local time on the schedule Yeah, we're eastern So whatever I say is eastern but the schedule it should adjust to your your uh Unless you got some crazy vpn going but it'll adjust to whatever time zone you have your pc Set to red and yellow hero and john wall IV What are you gonna go watch? Was there a rocket launch or something? maxi cameron johnson palo rated rookie Cole anthony light blue to 25 magic Magic red and yellow jaylen williams rated rookie thunder Those are all top bones highlands moody Yeah, it's it's uh high-risk high reward as they say That is a ton of work six. It's like it's a lot a lot of like tedious stuff johnny davis blue to 25 rated rookie for the wizards lude dorts j dub in there kelly ubré agbaji rated rookie red and yellow for the jazz murray red and yellow seth curry nets luka red and yellow jaylen durin Got tatum and tray murphy the third Still got to see oppenheimer still got to see barb. We haven't seen any movies Are we gonna see oppenheimer? No, I didn't have no time. Oh, yeah, you're right Red and yellow coro jayjon tate. Have you seen it? No. Oh, come on donny She had on sharp I'm sure I'll see it eventually sometime, but Probably not Oh, watch the brakes on the deck. Oh boy anthony and westbrook Steve, I'm gonna have to have to kindly pass on that To 25 bruce brown nuggets Minot tea wolves red and yellow rated rookie barry smith in there Marjahn bochamp bucks rated rookie red and yellow auto Nice on bucks barns and viscel eight more boxes Then you turn steve down Yeah, donny's always busy Avoiding steve red and yellow cody martin and koai lennard. Yeah, that's yeah, that's why I'm always busy Donny was talking a lot earlier now that steve's here. He's all quiet Yeah, I'm saying Oh be topping trevor keels red and rookie red and yellow for the nicks Really quiet really quick fish in lake 25 ben simmonds for the sixers not sixers the nets the nets Jones Middleton and anthony simons You don't play that role.  So anything ordered now. We'll go tomorrow morning Washington kenneth lopton junior rated rookie appreciate a lake We have if we have it in stock You can order it for rip tomorrow morning 10 a.m. Start time 10 a.m. Eastern start time Nice kid 25 for the pistons Harrison barns kings red and yellow barrett and bullock Patrick Baldwin jr. Rated rookie All right a few more here. John wall to 25 clippers Minot rated rookie red and yellow teawolves See another big auto here Jalen williams So again vet base split even got lamello j crowder Kessler Luminance comes out donnie you saving up Joe harris david roddy rated rick as much as i'd like to say yes, uh Oh, come on. I gotta clear some tech first Then we're then it's all uh All sales forward We're off to tahiti We've seen a couple boxes of luminance. We've seen a couple boxes of luminance in tahiti towns and helden johnson Collin sexton rated rookie is johnny davis for the wizards It's a sharp Chet Got light blue 25 cg mccollin for the pelicans Red and yellow conley for the jazz for the jazz yep Oh, apparently they're uh, they're remaking the original red dead The original red dead revolver no red dead redemption red dead redemption. Okay But they're supposed to be remastering it. So I definitely want to play that one Then I play the original Play that one It's a good game. That's what I've heard At your point in the second one. I was like, oh God van vleet kennedy chandler rated rookie for the grizzlies red and yellow We've taken that noise terry osear kevin herder j dub All right cameron thomas a bonus keegan murray Caleb houston rated rookie light blue auto eight of 10 magic We'd go magic buddy heal jalen durin rated rookie red and yellow for the pistons That was a good pack three more red and yellow mpj use of nerk itch sumu and jalen green That's Simmons Caleb houston rated rookie red and yellow for the magic palo I think he's a shooting guard Yanis and jammy grants So he view on the or lamb to starters or see a bench guy give you a bench guy Hopefully he can develop into a good shooting. All right last couple And guys just some football some optic retail and some starware sapphire left for tonight Personals are totally full Definitely over full. There'd be some left over for tomorrow morning Seven to go optic retail 19 to go optic retail Mowgli and kawai Chet Window carter jr. Trevor keels rated rookie Thoughts on preseason so far donnie Uh, I didn't watch the all-time game. So I got nothing Neither did I because it's preseason. I still watch it. I just hear and you didn't have it So the andrey hunter and for these simons. What was it? What was the boy network was it on peacock? There you go streaming battles Yep, they started It's like all every Thursday last year couldn't watch her as an appleball because you have prime on the tv red and yellow folds and a Bertans shade on sharp red and yellow and bead andrew nemmar rated rookie I don't I don't know Steve. I don't know if I have a favorite movie I thought I was gonna be barbie, but he doesn't want to see it donovage pj tucker or such a 20 guy Don't I probably say a range of the sift No christian brown rated rookie red and yellow again for the nuggets Blue to 25 basely for the thunder Aten and the last few rookies here is a j dub All right, so much dust Really quick auto recap that christian brown red and yellow twice Blue to ten Caleb houston red and yellow boat champ and blue to ten jaylon williams Solid case there. Thanks to get everybody moving on to more basketball


Arcadia is a really really good team they're young like we are I mean we have a few you know seniors and juniors on the floor But you know they're young like us and they just for sure thought that they could beat us in our home gym And just spoil everything you know the perfect season which can happen in sports Yeah, and they were capable of it except we didn't let them I mean we just took it to him from the start The first set I kind of dictate kind of dictated the match I think where we served and blocked really well and that you know kind of Gets in the back of a of a player's mind even nice players like at Arcadia The second set was close. I think the third set I think they were up six to one and I'm like thinking do I hold keep my timeouts for the 20s Or is it gonna be too late and the guys really responded down six one and and then I Don't know we were got caught up I think around the 10 10 area maybe 9 9 and and then I was like acting like I was a player I was just going now now now's the time to do it and they did you know because you're up 2.0 You want to close and and they did and I'm just really happy for the team Yeah, I say Jason maybe had the best match of his career. I mean I've only been coaching him You know two years, but he That was definitely we needed that kind of performance and we're gonna need that going forward like when I handed them the the award for Tournament MVP was it that I said, we're just starting. He said that's right coach. I'm ready You know, so he's got a great attitude. He wants to go further into the tournament and And with that kind of playing we will I mean well, we We'd upset anybody. It'd be nice being an underdog. I think now a little less pressure We're not really expected to beat anybody like I was saying I I wasn't looking past this match What I told them I always speak to him in a huddle after the game I told them that this guy's the limit for him because when they play well like they did tonight They can upset anybody and we're probably gonna have the top-ranked team in the country I think coming out of a new New Mac, you know, there's no real respect for the Mac yet, but we're gonna get some respect


pk611 will return you know the data in some format OpenSL will expect a slightly different one maybe it doesn't play with it but eventually it will come back to the application and you have your signature from the point of view of the application the application just called OpenSL to do a signature everything under the first layer is completely unknown potentially by the application I think that's the nice part so what are the hard areas multiple times encoders and decoders the concept is very simple but you have to know about the ASIN one for example all of the providers the internal ones and the external ones use at least 5 layers of nested macros to implement the functions that implement these encoders so when I was trying to understand what was happening it was really really hard maybe it was completely useless to follow what was going on and I just went trial and error until things worked eventually I understood enough to actually correct the first few mistakes ahead and it kind of works but it is really really difficult code and then there is naming and caching resolution within OpenSL itself because whenever OpenSL tries to do an operation and tries to find which providers can complete that operation like for example RSA it has a whole world where it looks for names and try to find them and cache stuff find function pointers I gave up on that one because every time I had I was trying to look into it the code is really complicated but I was also trying to solve another problem and the other problem was more important so maybe it's just me but I just say keep it on faith it works most of the time sometimes like I ended up just looking other code was doing maybe I'm doing something wrong it wasn't working but you can largely muscle ignore it but it is a really complicated code maybe it would be nice to have a guide on that from the OpenSL side but it's not a showstopper but those are really hard areas it's really hard to understand what you're supposed to do there's still one thing I don't understand maybe I'll ask the pencil developers about the query operation for the function that is a query operation that says don't cache this and if you do that what happens is the opposite OpenSL would only use that thing for their own and it was like what so I stopped doing that it was fun but the next steps for me or the project in general is integrating with applications because as I said you have to use the OpenSL 3API fully to make use of the providers so we did some testing within the team we believe SSH stuff mostly works some bugs were found but that should be we should be able to get that working but I want to work on ISC bind SSH and Modest Cell to make them use these instead of engines that's where we'll go next a lot of bugs were found in the making of these slides but nobody was hurt there were PRs open there were discussion upstream OpenSL developers were mostly very gracious and useful and understanding and accommodating and we fixed things there are still some things discussing there are still some areas where the provider API can be improved to make things easier or possible but overall it has been a very fun experience for me so thank you all and if you have any questions yep, go ahead my question is it's just an example of a fix a fix a moving file for fix the moving file has two providers the name is base and the name also is named fix and I was told in that case of a moving file the base is used as a coding and the fix is used for encryption and I wonder how OpenSL have some which provider is used for the coding so the question is in fix mode when you want to use a fix provider there are two providers you actually have to configure one is called the base provider and the other is the fix provider and the base provider does encoding and the fix provider does encryption primitives and how that works but I didn't say although there is this impression that the provider is monolithic like it says one thing from the point of view of OpenSL each provider fundamentally gives you a palette of providers to choose from each operation is kind of its own provider within the provider and each one of them has a name and a function table associated so when OpenSL needs to do an operation like I need to decode something it will query all of the providers it's more complicated than that but let's say it queries all of the providers and we'll find which provider tells back to OpenSL I can handle this and then OpenSL has some logic to choose which of the providers it will use so in the case of the base versus fix provider the fix provider doesn't provide any encoder or decoder function so whenever OpenSL ask for a file the fix provider will not respond but the base provider will say I can decode this and that's how OpenSL knows that it will use with the base provider for that what is more complicated is what happened when one provider for example decodes a key and then you want to use it with another provider but I don't go there unless you ask for it it seems like the important thing to mean to port applications is the switch is using this OSSL store how would we get then the automatic association and a specific provider or say if I've got a PX7 or a user how do I know to use your provider for that URI versus some other provider on the system so the question is if applications reach to this new OpenSL store API which is what is needed to use provider and passes in the URI how does OpenSL know it has to use the PX7 provider versus another provider in multiple ways that are implemented to influence which provider is being used so first of all providers can register into an OpenSL a handle for URIs and so the PX7 provider registers into OpenSL I can handle anything that is PX11 column something so whenever OpenSL is given a URI in the store case or slash because there is a shorthand there it's PX11 column so which provider handle this it will find that the PX11 provider handles it and it will call the store operations in that provider now what happens after that is that the PX11 provider will return an object reference for a key for example and once you will you know embedded into EVP key structure when you do an operation with the EVP key structure then OpenSL will go in and look into it and say oh this key is owned by this provider let's try to see if this specific provider can handle the operation and be asked to do and if it does it will prefer to use that provider and if that provider does not support the operation what OpenSL does is it will ask the provider can you actually export this key to another provider and use it in another provider so this is the general mechanism but you have things like properties for example to tell OpenSL well you should really only ever use providers that expose this property and never anything else even if they say they support operation this is how for example the FIPS provider is actually really used because the FIPS provider is fundamentally the same code base as the default provider the difference is that when you set the property called FIPS equal yes then OpenSL will only use the provider that exposes property which is the FIPS provider so there is this selection mechanism within OpenSL that either the application can pass in or the configuration file can be set to that allows you to select specific providers where multiple of them offer the same functionality that's how it works in the international yep I wanted a little more of that can I do that with standards or does that need or will the FIPS provider have to know if I'm going to load more than one than one so the question is I want to load more than one than one module ok so the question is can I load more than one the question is kind of more than one pxs11 module my question to you more pxs11 drivers yes because the pxs11 provider is kind of a module itself which gets loaded dynamically into OpenSL if there is configuration and then the provider itself currently loads one driver so if you want to use multiple tokens there are multiple strategies that you can go for one is different applications use different tokens you will have a custom OpenSL.conf file for each application and in each one you will set the driver or you set an environment variable instead of setting the driver into the configuration and you set this environment variable for study application that's another way we support to load different drivers and that's what we use for example in CI when we test different drivers or you use something like pxs11 kit that can aggregate multiple driver underneath it's basically a proxy information there so there isn't a single way to go it will depend on the situation and what you need to use and how you need to use it so I have never tested whether I can load the same provider in OpenSL multiple times so it but I haven't looked at that this is the same provider with multiple tokens this is actually the load by the pxs11 kit proxy which basically aggregates all the devices that are installed in the pxs11 kit so if I do not provide configuration in the pxs11 module it's a load pxs11 kit that will basically load the pxs11 kit we have a build option where we will load by the pxs11 kit proxy which can collate multiple drivers available in the system by doing some discovery and so it will make multiple driver available and this work just fine because through the pxs11 URI you can always select specific module you want to use even if multiple modules have keys that are named the same way so there is no ambiguity unless you forget to set those parts it's possible in the end to have multiple pxs11 modules load at the same time we are out of time, thank you so hello everyone welcome to this very last session in the devconf my name is Daiki Ueno I work for RETART as a real crypto team like CIMO so the title of this talk is a question about our systems using up-to-date cryptography so today I'm going to talk about a tool we are currently developing to give you some answer to this question that is to monitor the cryptography usage on our system to be a bit louder so I don't have a strong voice so it's very hard but anyway so here is a motivation so it's no doubt that cryptography is going to work and there is a problem that every cryptographic algorithm has its own lifetime so it will be eventually vulnerable so for example, triple death and MD5 are already known to be vulnerable for quite some time and it's turned out recently that the shower can make a collision with moderately priced computers and it's also said that there will be quantum computers coming and they will break existing asymmetrical cryptography like ECDSA RSA, something like that so the best practice is to regularly review your system configuration and update if needed to use the newer cryptography algorithm but it's not that easy because if you suddenly stop supporting some particular algorithms there might be some users that are still using so they will be probably upset if you are providing public services maybe you will lose customers or users so that is bad so the first thing users need to do is to identify how much the algorithm set is used in the world so to identify the cryptography usage on a system we came up with a simple idea to identify the system crypt libraries with some instrumentation called USDT and attach the BPF program to each user space program and monitor the capture algorithm usage and generate some statistics so we have a couple of case studies in the past so one is that is to gather statistics of TLS ciphers with usage the next one is Shawan SIG Tracer tool created by Alex to check the feasibility of duplicating the Shawan algorithm in Fedora the change itself was eventually rejected but it was proven that this tool was useful so the idea is that we are making this tool more generic so yeah, so there are many challenges actually, so to make it generic so the main concerns I listed here three things, one is the efficiency so it's not zero cost to attach the BPF program and monitor the other three things but we shouldn't affect the entire system performance so it shouldn't be unusable and also in theory we can collect any information from any user space program but we shouldn't collect too much so we shouldn't collect user's private activity or something like that and the last thing is maintainability we are modifying the upstream cryptographic libraries so there will be some burden to maintain if you add stress points or something like that so we need to make it minimal cost to maintain so to address these three challenges we are designed architecture and logging mechanism so here is architecture diagram basically it consists of three components so agent and event broker and some clients attached so agent just installs BPF program into the kernel and this BPF program is attached to each target program and it receives some events so it sends it back to agent and agent just writes them into a disk file and there is a separate event broker process that can monitor this primary log file and distribute events to the subscribed clients then finally the final statistics can be used by any clients so this is the text description of what I say so let's move on to the logging format so usually cryptographic events have some context attached because for example in this case sometimes signature RSA-PSS is used but where for what purpose is it used unclear if we just record these events so we make it structure like hierarchical manner basically there is a prior we just follow the pattern using distributed tracing so we categorize event types in two one is context context means a period of time where events or any other context can occur and the other is event it's just an event it represents the event itself so context is as I said it is just container but it can have some name associated also it is identified with 16 bytes identifier so it is tend to be private information so it is obfuscated by the agent when it is received so for TLS we defined some set of context names like TLS handshake for client and TLS handshake for server and certificate signing for certificate-based authentication and also key exchange you know TLS handshake consists of multiple phrases so it corresponds to it so the event event is just a key value pair that's a single event data so for example protocol version is encoded as a unit 16 value that means negotiated TLS version and TLS ciphers is as well a signature algorithm key exchange algorithm and group so there are more but so conceptually context and events basically looks like a tree but we need to encode them because otherwise we can't write it in a file so we choose this representation using the four primitives one is new context that's just introduced another context from the parent and three event data they are just key value pair with different types word and string and block so for example if we encode these events the handshake client with context ID 00 to 01 with this event protocol version 0304 and also another context with 002, 02 events so this is kind of a tree and it can be encoded into this way so context is opened and this string event is emitted this is just assigning the name to the context it is handshake client and we have protocol version event and another context is opened and name is assigned and two other events are encoded so it's as you see it's two variables so we implement some optimization so 16 bytes is too much basically it costs a lot of disk space so if we just save the file in this format it will eat up your disk space so we we apply some grouping mechanism that is to make multiple event into a single event entry so it will make it much smaller and also we implemented rotation mechanism so if the programming file reaches the limit we automatically create a backup file and open a new file so that was the login format and we need to modify the crypto library to instrument the same information and we provide this helper macros it's exactly matches the four primitives we provide so I'm sure if it meets the challenges but we tried and for FSC it is addressed by simple design of agent it simply just writes a file it doesn't do anything as any other thing and events are grouped so written data will be to be small for privacy we only added this mechanism that is to encrypt and obfuscate the context ID and the maintainability so as you see events are described with only four generic so it should be easy to use both crypto library and also the agent side so let me show some demo it works with network do you see well, okay so as I said the demo installs and running this is the agent it's running on the system and this is also event broker it's working let's start the client and try to use TLS sorry, I didn't start it so again so more interesting example is just using your application for example maps so actually I am living here around here but for example as you see there are some interactions that is basically it's created and some information is also captured so let's save it into binary file and capture some events let's use the long parcel so the events are now rendered as a tree so context has events and it has some child spawns new context and also it has some events so it can be rendered like this in a tree format so we can generate a frame graph like power math tools with script so data is written to html there are multiple TLS handshake happened and all the information you can browse and you can also import it to graphana or any other visualization platform so I created dashboard for this so this is the same frame graph and also you can count the actual TLS ciphers it's used with a simple SQL so you can just write something like that okay that's it for the demo so for the implementation so we recently started GitHub repository it's all public and core components are written in last and most of them are written in async style for performance reasons and for bpf access we use bpf rs there are multiple implementations of bpf but we choose it and event broker uses tarpc create for binary based on rpc and other scripts are written in Python and we also provide a couple of utilities to access the logs and event broker so we need to also modify the crypto libraries we have an experimental package with these instrumentation in my corporate property so we already created open SSL so they can be safely installed but be careful about it so so future work so we eventually move this instrumentation to upstream and further use cases and we also after that we also plan to implement something in the higher level programming languages like Go and Rust and lastly we want to support more protocols like ssh, ipsec, dnssec pgp and other things the Grafana data source is currently just batch analysis but we can also create a plugin to support a real-time analysis also event broker is currently not socket activatable, it's just a restriction in the dependent but we can make it a socket activatable so it is not always running on the system so I don't know it's ended earlier but the conclusion is that our new project is called crypto auditing aims to create infrastructure needed to monitor the crypto usage on a system so we are trying to use a ground generic and the architecture of the project has been presented which comprises agent and event broker and clients also log-homest was presented so that's it any questions yes I saw the copper repository for this program so the question is that we have we currently have only copper but whether we have a plan to create an official package that is the goal but we probably should be upstream first so if the upstream accepts we can make it official so that is the plan yes I had numbers but I forgot yes so the question was how much power must overhead we would have if this is enabled I think we had some numbers but I forgot but it was around 20% if we are actively monitoring everything but we need to re-evaluate afterwards yes the question is that so if we want to monitor all the crypt of primitives we need to instrument all the crypt libraries and also the copied code that is correct and that is in particular a problem with some ecosystem they are using static linking so yes that's true and we currently focus on shared library but we will probably find some way to address the static linking situation yes yeah so I might not understand your question but the question is that yes sorry yes yes different criteria in the system they need to update the coding file of the application is that right so the question that so if the existing user is configured your system with 5th 140-2 will eventually migrate to 1-3 and whether it is needed to change the configuration but it depends on the components right and also how the 140-3 is enforced so I think that kind of enforcement is done by crypt policies system-wide crypt policies in Fedora so this is just a monitoring and give you a hint of how many that's correct other questions


The Pikeville Fire Department and many in the community are grieving the loss of firefighter and inspector Robert W. Lindsey who passed away on Tuesday, March 26th. Robby was very influential to our department here. He worked as an inspector, a firefighter EMT. He done a lot with technical rescue for us. And just overall, I want to say Robby would give you the shirt off his back. He was that kind of guy. So anytime you ever needed anything he'd be the guy you could go to. Lindsey began his career in the 1980s and was a beloved member of the Pikeville Fire Department. The former fire chief possessed a wealth of knowledge which he took pleasure in passing on to his colleagues within the department. As far as the legacy that he left behind, each member has taken a lot from Robby. He's worked very well with us in the past and trained up all these guys. So his legacy will live on through them and we'll make him proud. Lindsey leaves behind a huge legacy and many within the Pikeville Fire Department will miss him deeply. Arrangements for Lindsey have not yet been announced. For Mountain Top News, I'm Kelsea Fidel.


Very good morning and welcome to the breakfast on Plus TV Africa. My name is Nyamgul Agadje. My name is Rimeh Paulsen. You're welcome to do this edition of the breakfast on Plus TV Africa and we're sure you're going to have a swell time with us because we have a lot of factories today. By the way, you are the chef so tell us what is on the menu today. Oh okay, so first we'll be looking at some topics first and we have NRC yet to recover from government's previous transport fair slash says MD and Rebandu tells AFCC to block funding of terrorism kidnapping and banditry so those are the two topics we'll be looking at but before that well we'll have some teasers as well as off the press look at what the national dailies are saying this morning and I'm sure you have yourself that this morning. Yeah well I just said something about you being a chef apart from the fact that we're going to have what you've just told us on the teasers and then we're going to have top trending issues. What is other menu also for Christmas? Oh definitely. Real from now. Definitely some chicken. I think Christmas is associated with chicken. How can you have Christmas and not have chicken? How can you have Christmas and not have rice? And that reminds me chicken this year in some places they're selling it for as high as 15,000 some for 18,000 even 20,000. Right. Wow that it's it's serious. Back at rice is about 100 or something right now. So we're going back to the days where we could only eat rice on Christmas day. Because when we were growing up rice was the thing that's why I think it just stopped to Christmas because that was the one time that we got to eat rice as we wanted it. Otherwise you have to be very rich a very rich family or very well-to-do family rice every Sunday. Not even every day. No you can't do that every Sunday you have rice and all that but it's like we're going back to that time and I don't know whether the government is doing anything really. Well they're doing something they they slash the boss prizes and give you free train rides. Please don't remind me of that. That is something the government is doing something. By the way today we're going to be discussing the fact that they have done something like this before and NRC which is the National Railway Corporation is yet to recover from from the losses let me put it that way of that time till now. So how are they running their establishment? I'm just wondering if they just want to make this the the railway corporation to die again as it died at some point I don't know but we'll find out. We actually asked this question and we're like you know where is the money coming from because at the end of the day we're saying you're taking out the boss fares or 50 percent of the boss fares and no money to be paid for the train rides. Obviously it is a business you should pay the business. Yeah even if it's run by you but you should still pay the business. So for instance the railway corporation should be paid you pay for the Nigerians that are going to go on that train ride and say oh you know what you don't have to pay but we will pay for you but not that you're telling them to do it for free they're running on whatever fuel that they need to use the staff needs to be paid and there's nothing for them so how are they supposed to recover? So I'm sure that's what must have happened the first time and that's the reason why it took a while for them to recover. And it happens in a lot of government establishments people politicians everybody just comes they just come and say okay do this for us and then they don't get to pay just because the government at some point gives them some subversions and all that but it shouldn't work that way. If you go to media houses for instance state run media houses most times press releases that come from all the ministries they get to be read for free nobody even thinks about it every once in a while maybe they just drop something they tell you we have retainer sheep and all that and it's not true money doesn't come in as it should come in and if the money from the government agencies and power status come to the media house I'm using media house now as it should come it can run even only soon without the money that comes from the government. It should be a profitable business you should be able to run the business without any other thing without you know funding from the government at least when the government comes and pays for the services when private enterprises come and pay for services you're running a good business it's just profitable. But here what they do is okay they come to you you run it for free they go to a private firm pay more than double of the money they should have paid you and then have it also add in the order of place oh. Do you know what I call that see finish see finishism. Oh she finishism. I like the word see finishism yeah okay well I thought I could go to all the places that that we have buzz terminals to find out what was really going on but I could not I'm sure I will try to go there today so that by Monday we should have a definite report of what is really happening so far all the people enjoying this all the people have called and tried to find out whether they enjoyed this bus ride because they traveled I've said no they didn't see anything like that but I'm not saying it's not happening so we needed to have known these transport companies that were contracted to do this because it can't be anywhere just everyone no information so they should tell us so that we know that okay if this XYZ is supposed to do this and they're not doing it we can shout and say okay they are not doing it so government do not pay them but now we don't know so anybody can just do what he wants and then take stumps of receipt to the minister of finance or humanitarian affairs I don't know are they will surprise you positively but they keep surprising me still yeah they keep surprising you negatively so you have to be definite and say I want them to surprise me positively well let's move over to some top trending stories this morning we have federal government reopens third million bridge after repairs the federal government is reopened the third million bridge one month after its closure for maintenance work says the leg the leg of state commissioner for transportation he commanded Nigerians for their patients during the temporary closure adding that the government understood the inconvenience the closure may have caused oh she and me maintain that the reopening affirms the government's commitment to infrastructure upkeep and public safety the move came over one month outside the federal government through the ministry of works announced that it will be closing two ramps of the third million bridge for repairs the november one move was announced by the federal controller of works in Lagos engineer mrs oikisha noted that the repairs works the repair works will begin with the ramps connecting or or shiki to adequately and Lagos island adini g adili to adequately simultaneously following the maintenance work motorists were advised to cooperate with the traffic management officials by obeying and observing all diversions and also using alternative routes the third million is that is africa's second longest bridge extending nearly 12 kilometers about 7.5 miles to link Lagos island the business heart of the city with the mainland where most people live it was built in 1990 in nigeria's economic engine one was built in 1990 by the babangida administration which is not civilian and it is not democracy uh well i'm just being mysterious this morning about second day is that uh when you see people trekking on the third main land bridge you just know that they are ready to go the 12 kilometers or 11. something kilometers just to get to where they can find food to eat or do the work that will put food on that table and it just worries me but i don't know if uh the repair works on the axis from yano woro to adini johad whatever the quality yeah if it was done in the midnight because i use that route every time and i've never seen people working on it i see them working on the sides they side going to a butaneta and the yeah the ramps yeah those places but the main i will call it the main bridge that comes from yano woro to the other i didn't see them work on them except the time when they filled the potholes on the yes however there's still there's still a lot of potholes there's still a lot of potholes because i applied that route last night there's still some potholes there so i think they just did a partial work they need to do the full thing yeah but at least it was a it is a lot better than it used to be oh yes definitely until the third main land bridge and you'll be afraid that your your tire might go bad or something on your car but if well let's just assume that it was those places that the ramps that needed to be worked on the main main bridge as i call it did not have the need for all those ones but could us do um the government because maintenance culture is a problem in Nigeria so if they can every once in a while think about what to do for a bridge like that and maybe any other thing maybe they should uh we should applaud them but let me use this time also to call on the um legal state government i don't know if that's their responsibility or it's a major federal road uh there's this pedestrian work way at um alakwery estate you know it there was an accident a few weeks ago and a truck these articulated trucks hit it and the thing broke so which means people can't cross the road through using that anymore it's only on one side that that thing is so they should they should yeah they should work on it so that people can get to cross the road it's dangerous crossing the road so if they are so used to crossing the road using the bridge and now there's been an accident they can't wait for the person who spoiled it who broke it because it might take him time to raise this money so they should do it and wait for the time that person can pay if that's what they're waiting for so uh legal state government please you've been doing well so just work on that pedestrian bridge because we even need more in lego so that people don't get to cross the road and uh face the uh the possible accidents that uh can occur if they cross the road okay well up to we're going to another story and i'm sure this one will gladden some people's hearts um protocol refinery begins operation yay finally let us see the fuel let's see the fuel come the federal government unfairly confirmed the commencement of operations at the protocol refinery and petrochemical company in rivers state it announced that the facility commenced operations on december 20 2023 as the first phase of work at the plant had been completed adding the refined petroleum products would start flowing from the refinery after the christmas break the government at earlier in the year repeated repeatedly stated that the potharkot refinery would begin operations before the end of 2023 the minister of state for petroleum resources senator heineken lupuburi who led members of the refinery steering committee to inspect the facility congratulated the nigerian national petroleum company limited and nigerians in general for the feat nigeria's refineries in potharkot kajuna and worry have been dormant for decades as the federal government has spent several billions of naira to revamp the facilities the group chief executive officer nmpcl malecari said the employers of the company worked day and night for over 9.6 million man hours to get the refinery back on stream on april 7 2021 um it has been reported that the nmpc officially signed a contract with tail moint spa for the 1.5 billion naira billion dollar actually rehabilitation program of the potharkot refining company i mean this is great news because we're hoping that fuel will be coming out and so the kind the amounts that we pay for fuel right now would you know just calm down i like the fact that you use the word hoping we are hoping i mean i bought fuel for 6 20 yesterday my body is biting me okay and i was in traffic for over five hours and i spent most of that fuel for 6 20 but it was three something at least it's still not as good as 100 and something naira but it's there's something of it i'm just wondering when one fuel moved from was it 89 naira to or 80 to 89 naira something but that was less than 100 good luck naira yes i mean everybody went and occupied occupy Nigeria now it's it's 600 700 in some places a thousand in some places in nigeria nobody's occupying even even the the the smallest road in nigeria we are so comfortable they deduced from is he strong is he strong because i remember occupying nigeria um i think i was still in uni then and i couldn't ever fly out of nigeria like the the airports were closed everywhere gas stations roads that was a ten naira race yes from what it was to whatever this they were saying they were going to do it and occupy nigeria those same people are in power now funny enough so um i used to produce plus politics which is later in the evening if you've never watched plus politics you can join um and one of the guests had said he was you know marching forward during occupying nigeria but that he did not know better than now he knows better now he knows a subsidy has to be gone so as at that time when there was just that you know fuel naira race he felt no we can't do this occupy nigeria make sure that this money comes you know back down to the amount of pain but look at us we're at 6 20 and you're saying you did not know better than so now it's okay for us in government now of course it's in government now we know better nigerians need to suffer that's that's the the light bulb moment that you that you heard they tell you you have to you have to suffer it's just like you know how in the bible they say seven years of farming and then seven years of plenty so right now we're going through the seven years of farming and i hope we will still see the seven years of plenty maybe it's not my generations come please it has to be in my time so that i can i can tell stories to my children and grandchildren that this is what it used to be and this is what it is now so keep hope alive but you know protaco refinery coming i wish they had definitely told us that because of these the price of fuel will come down they're hush hush about that with me there's possibility there will be a lot of fuel but the price might still be the same thing and if that is the case then there is no progress that we have made because we want that progress to be such that the nigerian people will start buying fuel for less than 500 naira at least because if it goes back to even 400 naira people will clap and say it has we have tried yes because what you used to take to the filling station to buy five liters of fuel just few months ago is just one liter now less than a so so what are we saying and i wish i wish they could have explored the technology that i'm just saying i say no v someone who doesn't know anything they could have explored the technology used by bow fire that's what they call it in the in protaco and all that i'm saying this because in rice production for instance there are rice meals that will will will meal the rice they will remove the husk from the rice and all that but it doesn't have the ability to remove the stones that's why sometimes you have this local rice having stones yes but there are also other machines whose only job is to destone remove all the stones so you can produce it from this small meal that can do it without removing the stones and just take it to the one that will clean it for you and remove all the stones so local rice now is safer than it used to be yes so if they could have explored the technology of bow fire and collecting this and cleaning it i'm just saying randomly and cleaning it in the protaco refinery i think it will be faster i think there will be more fuel and then it will be cheaper because the technology is yes a better process yeah so sometimes in my village we have the meal that was one at one point the biggest meal in rice meal in in africa now it's not the biggest i'm sure but it used to be the biggest meal in the 80s and early 90s now if you can mill your rice somewhere else you can take it there for cleaning you know it polishes it and removes the stones for you and you take it home if you go to a back leaky it also happens that they have a lot of meals this in fact a community of rice meals that can do this without cleaning it and then you take it to where it will clean yeah so if they could explore it's just a division of labor yes they could explore the technology which is cheap enough and then see how they can take it from there and say okay since this is this may not be as clean as it is which i don't know anyway because people have been using it and they're not complaining if it's not as clean as it should be pass it through this and then we'll clean it for you and all that yeah and if they're even bothered about you know it being illegal or something grant us people licenses quantum licenses to be able to operate even you do it if you if because that technology is cheaper it must be cheaper right for people to be able to do it in their home it must be cheaper so explore that and see how you can develop that there are people who have read courses that can do things like yes commission them let's them see how they can improve it so that we'll have these cottage meals let's say or cottage refineries that's how we'll call it a lot littered everywhere and we can get our own crude oil and refine so some of these people who do not even want to sell in Nigeria that want to smuggle it and all that they will have a legal business we buy crude from Nigeria we we refine it and our own is to refine and sell to other countries right it's legal business but you know i'm not saying like an expert politicians must be well if you are an expert please advise us i think that we should get someone to advise us on you know how to go about it will they advise us well the government advice the government on how to go about it and hopefully i mean fuel can just reduce in price small please it would help us okay let's move over to our last uptrending and this one gov now bearding laments rise in court is in cases the urban state governor duck ball a bearding has expressed concern over the surge in cultism and the attendance bloodletting in the states urging the department of state services dss to devise measures to fight the criminal act to a standstill a bearding highlighted that the prevalence of court activities which was never a major issue in the past is now becoming a huge source of concern and quite worrisome to the residents of the state the governor disclosed this on thursday at the southwest donald conference of state directors of security held at um somewhere in abel kota the state capital while addressing the audience of security operatives a bearding express worry that even school children and adolescents were also involved in courtism a bearding said that an urgent need for the man of the department to understand the motives behind such involvement the reasons for the escalating violence and killings among court members and the incentives that attract individuals to join the groups in the state the governor equally urged the dss to investigate the root causes behind worrying this worrying trend speaking at the program the director dss organ state command commander for lasha day adi kayoja assured the governor of a safe and more secure organ state adi kayoja assured that the department would continue to work in synergy with other security agencies to effectively combat insecurity in the state the dss's boss who expressed his pleasure at the at the southwest zone as we marked with kidnappings along highways pledged that the security agency will combat the menace with experience and expertise gathered from his relationship with other sister agencies um so i've i've heard of you know kids even joining court kids in in secondary school from secondary school they start they're joining they started with clicks they say oh you know we just we're just a click of friends and then they move over to universities and they join calls but now we're even seeing that the court is moving into secondary school and from this statement that we've read even attisans people in this state joining this court they're asking what the incentive is first of all a court is a gathering of people with like minds they have the same ideologies and all that it doesn't have to be a a bad thing even a church can be described as a cult in some way in a positive way because they're not gathering to kill people and all that the incentive um why cultism entered into nigeria in the first place is to fight inequalities that's why showing car brought it is the father of cultism in nigeria and i'm not sure what is happening now what's his intention yeah because they have to fight for good grades they have to fight for their rights in the school and all that so he came up with that that is understandable but right now if you're asking of the incentive i'm sure they know already what the incentives are um a lot of people in the political sphere are people who have been or are still members of course yes so there is no cult in nigeria that doesn't have a very highly placed politician right now in our country but you can quote me anywhere whether you think it's very local whether i think it's sophisticated or not they must have one person at least that is high up there so if you can find a governor because we've seen cases where some governors fly the colors that's what you're saying yes they fly the colors of some particular calls red blue and you see that the people that have been given appointments are in some way related to these cults and all that right then what other incentive are you looking for and if the dss does what they do and i'm sure they do i'm sure they have a lot of names of people who are highly placed that are already cultists just like the half the names of the people who are sponsoring Boko Haram and nobody has ever been arrested so let's just stop asking us what the incentives are so i think this is what it is right most of these people they'll tell you they're in a confrontanity oh you know what we're just we're just friends group of friends gathering together moving for um and the same ideologies right that's how they would they would say to you but guess what the little ones who are joining this court most times are being used as puppets they're being used to carry out to carry out their activities so the bad activities that these politicians would naturally not put their hands into they will send these other ones to go do it so that's the reason why they keep recruiting these people and those are the incentives why are you talking about incentives obviously if i have someone who's a you know highly placed politician backing me up even when i do something bad if i'm if i'm arrested this person will come and you know bill me out if i need money i can get money from this person um you know just that power that you know that is backing you obviously those are the incentives that these people would have to join this court i give you two two two short stories i was teaching in one school in akwaibon state in okuma back a christen secondary school that's how it is nigerian christen secondary school and in ss1 a lot of them were 14 15 the oldest was 16 guess what there was a very huge problem of cultism in that school and my students of 14 15 were part of it wow this is like uh how many years ago in a very early 90 i think 1999 19 oh well not not early 90 late 90s 99 2000 they were 14 years some of them were bearing gospel names in fact one of them was actually called gospel wow it was a big problem so the principal had to come out call all the children out some of them were just as three and they were already joining they were already in a cult in fact there were so many bad things such that at some point i was teaching them a something on literature and i asked them a question that they were supposed to ask me it is because of love they were supposed to answer that and they were telling me because someone was if you read you've read the lion and the jewel there was someone who was so so obsessed with the girl and even when the girl rejected him he didn't want to live and i asked what was the reason i was expecting them to say a lot and they were saying uh sir it maybe is kubu no mi you know what kubu no mi is no it's a love potion oh wow 14 years already for further the way they were telling me they were mentioning names you did it that time hey i know but you did it too i was just looking at them like i was sweating even when it was summer time but that's one by the way uh the second thing is that when i started out as a broadcaster early in crossing the state there was a community that was so plagued with this cultism and they knew the people that were doing this they were killing people so the community heard about 15 of them came together went to the police and they identified this people killing me wow anyway let me finish my story they identified these people got them arrested okay they gave they brought a list with the approval of the police they brought a list to us to announce because these people were wanted they were running away from the community and all that the police declared them wanted they brought the list to us


So today I'm going to talk a little bit about what the role of a medical oncologist is a lot of people when they're going through this process. I have a lot of questions in terms of where the various people fit on their team and what their various options for treatment are. So I'm going to try and mimic a little bit one of my initial discussions with patients when they first come to meet me.   As you'll see from the moment that you get that initial abnormal mammogram to the moment that you come into a medical oncologist's office. So we have our radiologist our breast imager. They're the ones who review our mammograms and MRIs perform the biopsies and to help dictate what additional imaging someone might need to best evaluate their breast cancer. And then we have our breast surgeon, who's in charge of coming up with the surgical plan, whether it's a lumpectomy, where you're removing just the tumor and some surrounding tissue, whether it's a mastectomy, and whether they need to take some lymph nodes. And they're one of the first people that you meet after the radio after the radiologist, then as a medical oncologist and medical oncologist like myself is in charge of determining what systemic therapy therapy that goes in your body that can go anywhere that a tumor can to both treat any cancer that you have but also to reduce future risk of recurrence.  And then we have our radiation oncologist who's in charge of doing radiation, Dr. Patel will get in touch in a little bit, and we'll go from there. So what is an amount medical oncologist so we deal with the prevention diagnosis and treatment of cancer, and we evaluate and manage the systemic therapy to treat and prevent cancer. So many women come to me after having a lung factory mastectomy, and say well my breast surgeon took out all the cancer I don't have any cancer why do I need to see you. So one part of our goal is to make sure that we don't hear from your cancer again that we reduce your risk of ending any future disease. So what happens when you come to your initial consultation with a medical oncologist to review both your personal and family history to make sure that if there's any genetic testing that's required that's carried out. We review all of the pathology that's a result of any breast biopsy and any imaging that you may have had. We may decide that some future imaging is ordered such as cat skins or pet skins that may not be necessary and we discussed that as well. So we review what's been done so far in terms of surgery or any other interventions and if anything else is required, and we come up with a plan to treat and to prevent future breast cancer recurrent risk and we work closely, typically with the breast surgeons, the radiologists and the radiation oncologist to determine not only what plan makes the most sense but also in what order that plan will be carried out. So what is breast cancer, and it's staging. So at the end of the day, all cancer cells are basically cells that have started from a normal breast cell, and somewhere along the way, while they were growing and dividing and copying their genetic material cells made a mistake, and they created cells that had kind of more focused on growing and dividing than really on being breast cells and so those cells that initially were, you know, more also to speak than become these immortal cells that are just bent on dividing and not really functioning properly. The staging systems are for breast cancer is based on the location within the breast, the size of the tumor and also the involvement of lymph nodes. All staging systems are different for different tumor types that's something to keep into consideration. A staging system for breast cancer is completely different than say long colon or other things. The distinction that we make is what's called stage zero breast cancer, which is called ductal carcinoma in situ. Very frequently ductal carcinoma in situ is confused with invasive breast cancer. And so what Dr. Carcinoma in situ is is where you have these atypical cells that are stuck completely within the duct. They're stuck there. They haven't gone into the breast cancer into the breast cells and haven't ever come in contact with any highway such as blood vessels or lymph nodes. So they don't typically have the ability after being surgically removed to come back elsewhere in the body. And so that's what ductal carcinoma in situ is. Anything beyond the stage one is invasive breast cancer, meaning that those cells have gone into the breast itself and each of them have an inherent risk of kind of going on to other places in the body, which is our main job to prevent. Many women asked me why did this happen to me? What did I do wrong? What could I do different? At the end of the day, the biggest risk factor for breast cancer is just the fact that one has breasts.  Only about five to 10% of our breast cancers are hereditary in nature. In terms of who do we decide we're going to send to a genetic counselor and do genetic testing, that's largely based again on someone's family history, the type of breast cancer they have, and also the age at which they have that breast cancer. The other things that can increase risk are people that we know to have dense breast tissue, history of benign breast disease such as fibroadenomas or other recurrent cystic disease, and things of that nature. In terms of lifestyle factors, there are several lifestyle factors that have been evaluated increasing risk of breast cancer and those are things such as having early onset of periods, in terms of having obesity, decreased activity, having absence of children or children after 30. We know that breastfeeding can decrease the risk of breast cancer. Alcohol use can increase risk of breast cancer. Interestingly, particularly greater than two drinks of dye can increase someone's risk as much as 20% compared to someone who doesn't drink alcohol. Things in terms of myths for breast cancer risk, there's myths out there that antiperspirants can increase risk of breast cancer, that is not the case. In terms of estrogen supplementation such as oral contraceptives or estrogen supplementation postmenopausal, we have shown a concern that these could potentially increase risk of breast cancer, but those risks are very low and actually only occur while someone's on the estrogen supplementation. What are the different systemic therapy options to treat breast cancer? We have many of them. One of the things I always tell people when they come to see me for initial consultation is to be very careful in terms of their googling and as well as when they compare their story to someone else. There are so many women who have been affected by breast cancer with whom one can kind of talk and kind of compare stories. But in terms of our treatment plan, there's so many different things that come into it based on a multitude of factors. We determine someone's treatment plan so that can account for why they very much can look different from each other. So we have neo-adjuvant therapy, neo-adjuvant therapy means any therapy that's given before surgery. For certain tumor types, sizes, other indications, we might try and give people therapy prior to their surgery with the goal of reducing the size of the tumor to make surgical outcomes better. Adjuvant therapy is any therapy that's given after surgery and the vast majority of our therapies are given in the adjuvant setting, meaning you do surgery first and then have your therapy. We have hormone therapy, which can be pills or shots designed to decrease the amount of estrogen we have in our body, which we'll get into. We have chemotherapy and we have targeted therapy, such as HER2 directed therapy. We have immune therapy and sometimes we just observe people. What are the types of breast cancer that are out there? And so one of the initial questions that we ask ourselves when coming up with a treatment plan is what are the things that are making someone's tumor grow, divide, and survive? And so here's where we come down to what is driving someone's particular tumor. So the vast majority of breast cancer is 80% will show estrogen and progesterone positivity, meaning that when they look under the microscope with the pathologist, the certain percentage of someone's tumor cells take up estrogen and progesterone. They're relying on the natural estrogen and progesterone we have in our body, and even postmenopausal women, even men all have some estrogen that's there, and these tumor cells rely on those to help them grow, divide, and survive. So we have HER2 positive disease, which we'll get into, and about 20% of tumors can have HER2 positive. And we have, and then you can have a combination of HER2 with estrogen, progesterone, positive tumors, or it can be HER2 without the presence of estrogen and progesterone. About 10 to 20% of tumors are triple negative, meaning they don't express estrogen, progesterone, or HER2 positivity, and those are treated quite differently than the above. So what is hormone therapy? The most common one that people have heard of is tamoxifen, and so we have what are also called the aromates inhibitors, which are letrasol and astrodol and epsomastane. When we determine what hormone therapy we're using, it's largely based on a couple of factors, the biggest one being whether or not someone is premenopausal or post. The difference between a premenopausal and a postmenopausal woman is a premenopausal woman is still making estrogen from her ovaries. The aromates inhibitors, which are the bottom three, are not capable of reducing the estrogen that comes from the ovaries. So if we give those to premenopausal women, they'll just make estrogen around them. Tamoxifen can be given to pre or postmenopausal women, but it's typically given to premenopausal women. They're blocking the ability of estrogen to bind onto those abnormal cells, and therefore kind of starts of cells of what they need. The letrasol and astrodol and epsomastane grants the conversion of hormones to estrogen in the body. What is chemotherapy and who needs it? So 70% of women with ERPR positive disease will not require chemotherapy. Therapy is almost universally given to our triple negative breast cancers and our HER2 positive breast cancers. As long as they're above a certain size, which is typically generally speaking around five millimeters, they can be different for different people. And so when we make a decision in terms of chemotherapy for hormone positive breast cancer, the vast majority of women won't need it. Because those tumors that express estrogen and progesterone care so much about that hormone, that as long as we deprive them of the estrogen and progesterone, we significantly reduce risk of recurrence by 50% or greater without the use of chemotherapy. It's not that chemotherapy is not beneficial in those patients. It's just not necessary. So how do we figure out who needs chemo and who doesn't? That's where the oncotype DX score comes in. So the oncotype DX score is a score used only in estrogen, progesterone positive, HER2 negative women with breast cancer is above five millimeters and up to three lymph nodes positive. What it does is it's a genetic test of about 21 different genes done on the tumor itself that's removed surgically to give us a numerical score, whether or not someone needs chemotherapy. The score for which we determine that someone needs chemotherapy can be different based on whether someone's pre or post menopausal, and also whether or not they have lymph nodes positive. Generally speaking, if the score is less than 25, the additional benefit of chemotherapy tends to be less than 1% or not at all. In our pre menopausal women, sometimes regardless of the score, we still make a decision to do chemotherapy, because in our pre menopausal women, there are other factors that can contribute to their breast cancer that are benefited by chemotherapy. That is HER2 targeted therapy. And so HER2 receptors are receptors that can be present on a fast sale and when they're multiplied in their function, they can increase the growth of tumors. We have HER2 targeted therapy, which are a variety of either intravenous or oral therapies that can go directly against these HER2 cells and prevent them from growing and dividing. They can be given to women with HER2 positive disease. Typically HER2 therapy in the setting of early stage breast cancer is added to a chemotherapy backbone, which can be different based on different factors. And the HER2 therapy can typically be continued after chemotherapy is done, surgery is given, someone's received radiation, that therapy can continue up to a year and usually longer. People ask, how will my treatment affect everything life? Many women are very concerned about this. I think in the setting of chemotherapy, most women accept the fact that you'll be given something for a period of four to six months. It can make you feel tired. You most chemotherapies, you do result in hair loss. People can have some mild nausea or vomiting, though typically now we've done a significant improvement in terms of managing these adverse effects. I think most women accept that chemotherapy might make them feel yucky for a short period of time and then they can move on. That's a harder thing to accept sometimes is hormone therapy. Adjuvant hormone therapy can hormone therapy given after surgery is typically continued for about five to 10 years. So to ask someone to take a daily medication that can affect their quality of life for five to 10 years is something that most people aren't too excited about. The good news is the vast majority of my women really do tolerate their hormone therapy very well and notice little to no disruption of their quality of life. Most of our hormone therapies have side effects associated with menopausal symptoms because we're reducing that estrogen. So it can be some fatigue, mood changes, hot flashes, achiness in the joints. The good news is even when people do have adverse effects, typically most oncologists are very good at dealing with the side effects. And also sometimes by switching one's medication, we can find one that people can tolerate. You know, we accept as oncologists that we're asking people for a very significant chunk of their life and really focus on ensuring that the quality of people's lives is not adversely affected. Overall, survivorship is a really big component of breast cancer care because so many women continue to follow with their oncologist for significant periods of time, a decade or more. We really do recognize all the ways that having breast cancer, even once it's gone can continue to impact people in terms of, you know, their anxiety around mammogram imaging in terms of their effects. A fax of hormone therapy. But the good news is that breast cancer, you're not alone, 7.8 million women in the past five years have been diagnosed about 280,000 invasive breast cancer in the last year and 50,000 cases of DCIS. Breast cancer has a 13% percent lifetime risk in one in eight women. So the community is big. Our research is strong. And the good news is with every year are outcomes of breast cancer, which are already fantastic. For 90% of stage one in two women will never see their breast cancer return, but those outcomes get better every year. And our risk of death from breast cancer goes down by about 1% to 2% per year. Thank you. Thank you, Dr. Salowicz. And yeah, we're just going to transition. We're going to have here from Dr. Priti Patel, Medical Director of Radiation Oncology at Riverview. So thank you and take it away. Just loading my screen. Okay. So thank you for inviting me to speak with Dr. Salowicz about breast cancer. My name is Priti Patel. I'm the Director of Radiation Oncology at Riverview Medical Center. I'm going to explain a little bit about the role of radiation for breast cancer. So radiation basically how I explain it to patients, it's an x-ray similar to like a chest x-ray, except it's much higher energy. And what these x-rays do is we target it to a tumor or microscopic cancer cells and the x-rays go right through them and they break them and they break their DNA. Cancer cells have a weaker DNA. And so they're vulnerable to damage and they don't have the proteins to repair themselves, whereas normal tissues, they do. So when we use radiation for the breast, for example, if there's microscopic cancer cells there, the cancer cells will die, whereas your normal tissue, even if they get some side effect, they can repair themselves because they have the proteins to do so. So that's the biology behind how radiation works. So external beam radiation therapy can be given either with a low dose per day or high dose per day, and I'll get into that in a little bit. And our field is pretty exciting in that there's been a lot of technology, it's constantly evolving, and the technology has really helped us protect the surrounding critical structures that surround the tumor that we may be treating. And it also allows us to deliver radiation more efficiently so that patients are not on the treatment table for that long. And radiation can be used to help prevent a recurrence in the breast. For example, if there's just microscopic cells that we're not seeing within the breast ducts, or it can help treat tumors that maybe are inoperable. Like in a metastatic setting or, and it also provides local control and survival benefit in breast cancer. So I'm going to briefly discuss the case and we can go from there. So if a patient comes to me in the consultation room. She's a 55 year old female and she had abnormal screening mammogram Dr. Salwitz went into how one of the first physicians that a patient sees would be the breast radiologist and so the breast radiologist saw an abnormal mammogram she suggested a biopsy of a one centimeter mass and the biopsies show that she had an invasive ductal carcinoma. So at that time she's referred to a surgeon and the surgeon discusses two treatment options for the patient. One would be mastectomy where you remove the breast. And the other would be a lumpectomy with radiation. And this is based on phase three studies that showed with 20 year results that removing a breast versus removing just the tumor and giving radiation to the breast afterwards which is called breast conservation that the results are equal that the survival is equal. And so patients that study helped us realize that patients don't need to remove their breast if they have a breast cancer that by removing just the lump and doing radiation afterwards their survival is the same. And in that same study they looked at, well what about the radiation do we really need it. And so when women where they did the lumpectomy, and then in women where they did the lumpectomy and added the radiation. The radiation showed a significant prevention of recurrence. So at 20 years. So the women that did not do the radiation 40% of those women had an in breast recurrence versus 14%. That did have the radiation so that study showed that not only does radiation help prevent the recurrence in the breast but actually it decreases a woman dying from breast cancer so it does help with the breast cancer mortality. So radiation is a very important tool in the treatment of breast cancer. And so the breast surgeon discussed these treatment options with this patient and she decided to proceed with breast conservation. And so she underwent a lumpectomy. And she is meeting with me to discuss her radiation therapy options. Usually, if a patient has a lumpectomy they will meet with myself and they will meet with a medical oncologist like Dr. That is where they would recommend if a patient needs chemotherapy or not if a patient does need chemotherapy they usually have chemotherapy first in this particular instance. She did not need chemotherapy she was recommended to have endocrine therapy alone which is a pill that a patient would take every day. And so that was the first couple of years which Dr. Selvitz alluded to. And so then we decided to, she came to see me about approximately four weeks after her surgery to discuss radiation. This is the case that we just presented about this stage one breast cancer patient she underwent surgery with breast conservation and is coming to see me for the first time for radiation. And so after the surgery for consultation, we review the history that I just did with this prior patient reviewing their imaging reviewing their surgical management, reviewing what the medical oncologist may have recommended. And then we discussed the different treatment options for radiation. And we talk about the number of days that they would need and the different techniques we can use to treat that patient. And then we also discuss the side effects and discuss our next steps. So I'm going to go into that. So, typically, when someone comes for radiation for a stage one breast cancer like this case that I just described, radiation can is typically every day Monday through Friday for about four weeks. We treat the whole breast for three weeks and then give a boost that last week of radiation to the lumpectomy cavity of where the surgery used to be. And women that have multiple lymph nodes that are positive, we end up treating a larger field and radiation can be up to six weeks in those patients. The nice thing about radiation that it is all outpatient, it is painless. Typically no restrictions during radiation therapy, a lot of the women will come to our department before work or after work and they can drive themselves. Side effects of radiation are typically gradual. That is why we give a low dose per day to allow the side effects to gradually accumulate. So basically acute side effects would be an erythema or a redness on the breast. Again, that's pretty gradual technologies come a long way where it is rare to get a very bad sunburn type of look on the breast fatigue.  Some term side effects, the breast can feel more firm or it's what's called fibrosis their breasts can have some tanning and a rear side effect is edema or lymphedema. You know, sometimes that can depend on the field that was radiated the number of lymph nodes that were removed. It can also depend on the size of the woman's breast. And so the technology has come a long way and to cardiac side effects are very rare. There have been studies showing that there actually is no increased cardiac deaths with patient that underwent breast radiation with the present technology. The risk of cardiac injury or secondary cancers or lung complications is almost less than 1% with the technology that we have now. So when a patient decides to have radiation for example this patient with the stage one breast cancer had a lumpectomy. She went met with medical oncology and was decided to undergo endocrine therapy, and then came here with radiation and I recommended four weeks. And so what we do in radiation is we basically do a planning session that's called a simulation. And what we do during that simulation is that we we figure out how to position the patient so that they're in the same position each day for treatment. It's how we map out the beam angles based on their anatomy. So in this particular instance this patient, we make this mold for the patient to lie in in the blue here. The patient is lying down with her arms up. They have a tattoo mark in the middle of their breasts. That is to align them with lasers in the room so that we can make sure that they are not rotated. And so that is the first step in planning for radiation. And then when the patient comes for treatment. As you can see this is the head of the machine where my arrow is. The x-rays are exiting the head of the machine in pink, and we deliver the radiation beams and what's called a tangential field. Basically we treat the breast with this tangential field on this angle to avoid the x-rays going inwards to the heart and lung. So one way we target the breast but avoid the heart and lung is by giving these tangential radiation fields. So as a patient's lying there, there's usually music playing in the room, and it typically takes about five minutes of radiation. They won't feel any pain. They get up and they will leave. So there's a few different techniques that we can use to deliver the radiation. Right here is what's called a Varian Trubium Linear Accelerator. This is the machine that we have in our department and in a lot of HMH hospitals. Basically a patient would lie down on a table and this machine can go around multiple different angles of the patient to deliver a focus targeted radiation. So radiation can be delivered with the patient on their back, which is supine. It also can be delivered with the patient prone or on their stomach, and I will show you a picture of that. There's various phrases that you may hear when researching about radiation, such as IMRT, IGRT, or VMAT, and I will get into that also in the next slide. There's a different way to do radiation also, and that's more of an internal radiation through a radioactive source, and I will go into that in another slide. We also can treat superficial tumors with something called electrons, which are superficial x-rays. And we can also, with these machines, deliver stereotactic radio surgery. Basically, that is a pinpoint very high dose of radiation to a very small spot. So sometimes in terms of breast cancer, we can do stereotactic radio surgery to target an area of metastatic disease, and sometimes we can even use it to target a small area in the breast. So just in further detail with all this technology that has really helped advance our field. The first one is called IMRT, and basically what that is is that at the head of the machine, we have these metallic leaves that modulate or move in and out as the X-ray beam is exiting the machine. And this really allows us to shape at a particular point in time the way the beam is coming out. And so for instance, this middle black picture is a picture of a patient, and the yellow is the area of the breast that we want to include. The red is her heart, the black is the lungs, and this green and yellow shading represents the amount of dose or energy that is being deposited from the radiation beams. And as you can see in the green shading that there is some lung tissue that's involved in this tangential field. But with the advent of IMRT, we're able to really shape the way that the radiation comes out of the machine. And now this is a much more conformal dose distribution. You can see that the green line goes from being here in this previous picture to now more closer to the breast and it spares a lot of radiation going into the lung. So this is another way that we can really treat the breast but minimize the dose to the heart and lung. IGRT is the concept in that we can really, when the patient's laying on a table, we can take images to really confirm that their positioning is exactly how it needs to be. And sometimes there's day to day variation. So that allows us to be confident that we know exactly the position that they need to be in. And VMAT stands for Volumetric Modulated Arc Therapy. The advent of VMAT allows us to really quickly treat patients. Patients are on the table and sometimes within just a few minutes, areas that traditionally would take 15, 25 minutes can be treated within just a few minutes. So this technology with multiple arcs or beam angles with IMRT really allows us to treat anywhere in the body, not just the breast but in the head, neck, brain, lung, pelvis, abdomen, etc. So in this patient with the case that I described she had her consultation, her simulation with the planning. This is the plan that we created and then she went ahead and had her treatment.  In this position, the breastboard is placed on the machine and they put their breasts through this hole here and the radiation beams will go, you know, inferior to this board. So it is an option for women with larger breasts. The special breast irradiation is the ability to deliver radiation to a smaller area, maybe just the tumor where the tumor used to be. For a select group of patients. So myself, the medical oncologist and the surgeon will discuss ahead of time if there's an appropriate candidate. So it needs to be a small tumor, not that aggressive without lymph nodes estrogen positive. And in those women, you're, you know, the risk of recurrence tends to be higher near the tumor bed of where the tumor used to be. And so we can focus the radiation just to that area. And that is a concept of partial breast irradiation. So partial breast irradiation can be done with a catheter this this is called a brachytherapy catheter where a catheter is inserted into the breast, and it's connected to a machine and the radiation delivers the radiation to the tumor bed, and it's typically done twice a day for five days. Alternatively, we can give partial breast irradiation with external beam radiation where we deliver beams targeted to the breast either with an IMRT technique which I just described, or, you know, five different angles that all converge to that spot. And so that is an option of getting radiation done within one week if they are an appropriate candidate. So case number two is this. So sometimes I get asked if we really need radiation in older women. So in this case we have a 75 year old woman with a one centimeter breast cancer that is estrogen receptor positive. She had a lumpectomy and she really does not want to undergo radiation and what is the discussion I have or what are her treatment options. There was a trial that specifically looked at this there was a trial that looked at women over 70 with one centimeter tumors. And these patients received a lumpectomy and either they had tamoxifen, which is an estrogen blocker with radiation or tamoxifen alone. As Dr. Salwood previously described, tamoxifen helps the body lower their estrogen so it prevents feeding the tumor if there are any microscopic cells left after surgery. So after 10 years, the patients that had the radiation and tamoxifen 2% developed the recurrence versus 10% that developed tamoxifen alone. So there is no difference in survival. So the conversation I tend to have with the women that are 70 or possibly even 65 and older is, I look at several factors. I look at their comorbid health conditions. If it is someone that is relatively healthy that can easily come for radiation then I do recommend radiation because it does help prevent overcurrents. So some women have a hard time tolerating these estrogen blocking medications and so if they do the radiation and they try the medication if they do not tolerate it for the full five years at least they've maximized their reduction in recurrence. However, if I have a woman that has multiple comorbid conditions, or it's difficult for her to be transported to radiation back and forth, then that may be a better candidate for endocrine therapy alone. So in summary, radiation therapy or technology, it continues to evolve to decrease side effects and allow us to give a very precise form of radiation while sparing surrounding critical structures. Radiation decreases recurrence is safe and it helps decrease death from breast cancer, and a multidisciplinary approach is crucial to cancer care. And in addition to the surgeon, the medical oncologist, the radiologist and myself, there are nurse navigators that are involved, there are social workers involved nutritionists involved genetic counselors involved. So it truly pathologists it truly does take a whole team to properly treat that patient. Thank you for allowing me to speak today.