Alison Tree 💙🇺🇦
@alison_tree
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Oncologist @royalmarsdenNHS , passionate about radiotherapy (among other things). Views are all mine.
Joined July 2015
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So honoured to have been part of the PACE team for the last 12 years. I have learned so much from
@nickva1
@EmmaHall71
and the whole team. Thanks to the 874 men and over 30 hospitals who partnered with us and to Accuray for funding. Abstract here
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In a world desperate for some good news, I am so proud to congratulate the awesome
@AnnaKirby17
@royalmarsdenNHS
@ICR_London
on becoming President Elect of
@ESTRO_RT
Shame we can't all raise a glass in person, but hopefully soon...
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My first Tweetorial 🧵 2 year toxicity results of PACE B published here. Big thanks to the 🇬🇧🇨🇦 and🇮🇪collaborators and the 874 men with prostate cancer who made this trial possible
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PACE-B 2 year paper finally out!
Tweetorial coming shortly, but firstly massive thanks to
@nickva1
@EmmaHall71
@royalmarsdenNHS
@royalmarsden
@Accuray
@VarianMedSys
@ICR_CTSU
@ProstateUK
and many more, for support of the PACE umbrella
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One tiny silver lining of this tragedy is that, at present, winning Love Island is no longer seen as the pinnacle of achievement in the world, but instead people seem to value kindness, caring for others and bravery. Let’s hope that lasts.
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Despite another trying year, good to see our sense of humour is intact in the
@RM_Radiotherapy
Christmas decoration competition. Glad I don't need to choose between the Penguin Cyberknife and the MR Linac igloo! It is truly a privilege to work with you all. Merry Christmas.
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Oligoprogression: Treat the whole lawn or weed selectively?
@drdavidpalma
@fifimcdrmh
@RCRadiologists
Lots of exciting research ongoing including the TRAP trial (thanks to
@ProstateUK
) and the HALT trial (thanks to
@CR_UK
@ICR_CTSU
)
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#PACE
A showing more urinary incontinence than expected
#GU23
Great presentation
@nickva1
and credit to whole team
@royalmarsdenNHS
@ICR_CTSU
for running such a difficult trial
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A real honour to visit Tata Memorial hospital and to attend the SOGOCON23 conference, meeting many multi-disciplinary colleagues committed to improving uro-oncological care in India. And they are running so many amazing trials!
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Delighted that the first DELINEATE trial cohorts now published
@IJROBP
. 5yr bRFS 96.7% with boost to 67Gy in 20; toxicity similar to non-boost literature. Thanks to Prof Dearnaley who set this trial up in 2011!
@juliarmurray
@PCaParker
@RM_Radiotherapy
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Shocking! Only 1.4% of global cancer spend is used for surgical research and only 2.8% on radiotherapy research. Please help us learn how to cure more patients by funding curative therapies research!
#radonc
The abysmal state of global research funding on key domains such as surgery, radiotherapy and health services. Combined less than 4%. How have research funding organisations managed to get their strategic priorities so wrong?
@cspramesh
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Great to see long term
results from OLIGOPELVIS, seems likely that cure is a realistic option for some patients (maybe 1/3rd) with pelvic oligorecurrence
#ESTRO23
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Delighted that we have achieved our accrual target for the TRAP trial this week funded by the amazing people
@ProstateUK
. Thanks to so many people who made this happen during a really tough few years!
@RTTQA_UK
@royalmarsdenNHS
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Delighted to report that the
#PACEC
trial recruited its 150th patient today (thanks
@RoyalFreeNHS
)! Great team effort from
@ICR_CTSU
@EmmaHall71
@nickva1
@royalmarsden
and a cast of thousands more, especially all our patients
#radonc
#pcsm
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Shout it loud people. NHS achieves better outcomes than outsourcing to private companies.
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Today we walked 15 miles to raise money for
@royalmarsden
This little hero carried on despite a sprained ankle at mile 8. Legend. Thanks to all our sponsors so far- here’s the link if you would like to sponsor us
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Another
@royalmarsdenNHS
@ICR_London
first today: first oligomet SBRT on the
#MRLinac
, as part of the PERMIT trial
@Gilly331
is looking happy about a job well done!
@Ian_M_Hanson
@H_A_McNair
@robert_huddart
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9
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Touching thank you from one of our lovely MRLinac HERMES trial patients today
@RM_Radiotherapy
@royalmarsdenNHS
@ICR_CTSU
@CR_UK
@RosetreesT
and the JP Moulton foundation, who fund the HERMES trial
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Stunning local control rates after 36 Gy in 6 fractions for bladder cancer, in a trial with a median age of 85! Nice work Robert Huddart
@royalmarsdenNHS
@ICR_London
#RCRconf2018
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Finally my
@TargetingCancer
hat made it back to its home!
#RadiationtherapyCuresCancer
@sandraturner49
@lucindamorris23
@_ShankarSiva
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Great talk from
@_ShankarSiva
on SBRT for RCC. Oncological outcomes look competitive with surgery- with only small drops in eGFR in most patents. Time for prime time in the UK now?
#ESTRO23
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To mark the 75th birthday of free healthcare for all in the UK, I have attempted my own solo
#NHSparkrun
#NHS75
Even found some water to run (OK, sometimes walk) by
@TylerSbrt
@AdamSharpMedOnc
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This is such a great session!
@VedangMurthy
showing us that we can safely treat VHR PCa, prostate and nodes, with 5 fractions. Can’t wait to see the biochemical outcomes, but will have to be patient 🤓
@ESTRO_RT
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Fancy a change of scene? Want to spend a year
@royalmarsdenNHS
@ICR_London
working with us? Suitable for a trainee clin/med/rad onc. We have an MR Linac, a Cyberknife,
@robert_huddart
and
@PCaParker
- what more could you want? DM me for details
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Congratulations to Dr Ros Westley (not on X!) on publishing the interim analysis of the HERMES trial - acute side effects rates low with both 5 and 2 fraction MRI-guided ART. Trial now fully accrued. Thanks to the JP Moulton foundation for support.
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@AnnaKirby17
powerfully advocating for embedding the patient’s voice in all our research. “None of us is as smart as all of us”
#ESTRO2021
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I’m lucky enough to work with Dr Pathmanathan and I’m delighted some of her pioneering work on the MR Linac won the 2020 BJR Barclay medal
@BIR_News
@royalmarsdenNHS
@Elekta
@ICR_London
@RM_Radiotherapy
Congratulations to Dr Angela Pathmanathan for winning the BJR Barclay Medal
@BJR_Radiology
@royalmarsdenNHS
#radiology
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Look at the amount of data in the
@MOMENTUM_study
! Over 70,000 MRI scans and 25,000 plans! What research questions can you answer with this?
#MRlinacconsortium
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@DrAndrewLoblaw
at
#ESTRO2021
. Surely everyone knows it tom-ar-toe, right?
#thecoolpeoplesaySBRT
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Thanks to this amazing team as part of the
@mr_linac
consortium! First steps towards MR-delineation and delivery in prostate bed RT
@kobikasri
and
@alison_tree
discuss the development of prostate bed delineation consensus guidelines for MRI-guided radiotherapy and assessment of its impact on interobserver variability in the
#RedJournal
.
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Honoured to be invited to the inaugural Italian MR-guided radiotherapy event, along with
@umbertoricardi
and Arjun Saghal. Thanks to
@alongi_filippo
and
@Elekta
for the invitation. MR-guided RT is exciting already and so much potential for improvement
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Innovative work going on
@royalmarsdenNHS
@RM_Radiotherapy
@Shaista_Hafeez
- targeting MR-adaptive bladder dose where it matters
#MRlinacconsortium
@mr_linac
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Anthony Zietman “Britain can’t punch its way out of the EU, but boy it can deliver RCTs”. I’m not sure whether to be sad or complimented...
#astro2019
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Delighted to announce that we have delivered 5# so far to the prostate on the MR Linac. See the video of day one in the link below.
Honoured to be part of such an amazing team!
⏰ Breaking news! ⏰
A Royal Marsden patient is the first in the UK to receive a pioneering new form of radiotherapy. MR Linac is the first technology in the world to deliver MRI scanning and X-ray treatment to patients at the same time. Read more >
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Delighted to see that
@AnnaKirby17
from
@royalmarsdenNHS
@ICR_London
is a candidate for ESTRO president. Her effectiveness, insight and desire to mentor others would be a huge benefit to all ESTRO members. Good luck!
@fifimcdrmh
@nickva1
@AitkenKatharine
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Heart-breaking situation. Glad someone remembers what honour is supposed to look like.
Apparently the UK Ambassador to Afghanistan (Sir Laurie Bristow) held out at the Embassy to get his people out first.
And now he's at the Kabul airport getting Afghan interpretors out one by one.
Extraordinary courage.
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18K
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@SullivanProf
@cspramesh
@AggarwalOnc
If radiotherapy costs were plotted on this graph, would they even be visible on this scale? High chance of cure (for many cancers) and still only a tiny % of cancer research funding helps patients who are treated with RT
#radonc
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Fantastic talk by
@SahgalArjun
on potential for patient benefit from MRI-guided adaptive RT in GBM. Could methylation status predict who benefits most?
#ESTRO2023
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Excellent point from
@PattyDiezH
@RTTQA_UK
- dose constraints are irrelevant if your OARs are not contoured correctly 🙌
#ESTRO23
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Very moving account of treatment
@royalmarsdenNHS
and including the truly marvellous
@CyberKnifeHelen
. Good to be reminded daily why we strive so hard for better treatments for cancer. Thank you
@bowelbabe
.
Deborah James (
@bowelbabe
) has been living with cancer for three years.
The
#YouMeBigC
presenter looks at the treatment that is prolonging her life ⬇️
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So overall, toxicity in 5 fractions is similar to 4-8 weeks of treatment. GU toxicity a little worse (on some scales) and GI toxicity a little better (on some scales) after 5 fractions with these doses and techniques.
Efficacy endpoints expected in 2023
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We are recruiting! Come and spend a year with us as a clinical fellow. Open to Rad Onc, Clin Onc and Med Onc
Please spread the word!
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So disappointing for all the UK patients who benefit from radiotherapy, and may benefit even more if radiotherapy research was properly prioritised by UK funding streams. Come on
@CR_UK
and
@theNCI
we should be doing better than this.
Yet again,
@CR_UK
and
@theNCI
Grand Challenges offer no opportunities for
#radiotherapy
research. And yes, we did submit proposals.
50% of cancer patients receive
#radiotherapy
and many are CURED by it. Huge opportunities to make it even more effective.
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Congratulations to the inspiring
@ethansgrumps
for completing his epic year of 5k per day. I still can’t run, but I walked 5k in the snow in your honour!
#movewithtony
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Brilliant video explaining that radiotherapy prolongs survival even in low volume metastatic prostate cancer. The
@MRCCTU
STAMPEDE trial raising the bar again
@PCaParker
@mattsydes
and nice shots of
@royalmarsdenNHS
Films about the results of the
#radiotherapy
comparison for
#metastatic
#prostatecancer
from
#STAMPEDEtrial
now available online. There's a 12 minute version () and an abridged 6 minute version ()
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I’m feeling redundant- soon I won’t be needed to contour on the
#MRlinac
. What will we do with our time?!
@kobikasri
@juliarmurray
Training for rad-led adaptive MR guided radiotherapy begins. Two radiographers contoured the prostate and seminal vesicles online under the watchful eye of Consultant Oncologist
@alison_tree
#mrlinac
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@_ShankarSiva
presenting the TROG SAFRON II study. No difference in oncological outcomes for multi vs single # SBRT for pulm mets
#ESTRO2021
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Really important paper here. Low toxicity and excellent biochemical control after urethral-sparing prostate SBRT👇 Congratulations
@ZilliThomas
and team
New in the
#RedJournal
: Urethra-sparing SBRT and OTT for prostate cancer: long-term results of a randomized phase II trial.
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Final tweet of the day from me, and it’s the best of all:
@achoud72
brings it home for the UK - hypofractionated radiotherapy is now SOC for MIBC
#ASTRO19
@robert_huddart
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Radiotherapy cures cancer! Inspiring day with
@TargetingCancer
@RCRadiologists
learning how to get this message across
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Nice piece by
@byFionaMacRae
describing the expanding legacy of David Dearnaley
@ICR_London
@ICR_CTSU
We are all standing on the shoulders of giants. Thanks to the JP Moulton foundation too, for funding HERMES.
@royalmarsdenNHS
In case you missed it in the Sunday Times
Doctors will this week treat the first man in a world-first trial that could lead to prostate cancer being cured within a week
@ICR_London
@royalmarsdenNHS
@alison_tree
@MovemberUK
@DrSuneilJain
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Despite the global pandemic, delighted to see lots of fantastic new UK radiotherapy trial proposals being presented and critiqued today. Radiotherapy is going to continue to improve and more patients will be cured
@NCRI_partners
#ncri_ctrad
#radonc
@MontefioreD
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Want to do a research fellowship
@royalmarsdenNHS
@ICR_London
on the MR Linac? Two posts available here, with me and
@AitkenKatharine
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Delighted to see our MR-guided prostate RT paper in the top 10 IJROBP downloads of 2018! Well done
@achoud72
@nickva1
@dr_vesi
and those not on Twitter, most importantly Angela Pathmanathan
@royalmarsdenNHS
@ICR_London
@Elekta
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What a privilege to work with this fantastic (and good looking!) bunch of people. 1000 fractions and counting...
Our Radiotherapy dept. celebrates a huge milestone today. They have just completed 1000 treatments on the
@Elekta
#MRLinac
almost 2 years to the day that the very first patient was treated with this technology at
@royalmarsdenNHS
@ICR_London
. An amazing achievement for the team!
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We have a long way to go
@TargetingCancer
Radiation therapy cures around 40% of curable cancers (surgery does most of the rest). Drug therapy is very important but we need to work together to improve outcomes.
@SbrtSean
Considering that this is the golden age of molecular oncology, why devote the next 30 years to anything other than medical oncology? Surgery and radiation have likely plateaued.
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Long time coming but v happy to hear Bas Raaymakers
@Cancer_UMCU
eloquently describe “True tracking”, gating and baseline shift correction for the Unity
#ASTRO22
. Can’t wait to get our hands on it soon 🙋♀️🙋♀️🙋♀️
@treeherb
@RM_Radiotherapy
#ASTRO22
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Oh my goodness this is brilliant! Please share to encourage men worried about prostate cancer to get checked (non-surgical curative options also available🙂)
🎶 Talking about the prostate isn’t always easy. So let’s sing about it instead.
The
@MarshSongs
family turned their grandfather's prostate cancer experience into a song to help men everywhere.
All profits raised from the song’s release will help us beat prostate cancer. 💙
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Two fantastic talks from
@royalmarsdenNHS
therapy radiographers
@H_A_McNair
@Gilly331
at the
@elekta
MR Linac consortium 2021. Rads/RTTs contouring prostates routinely now on the MR Linac, early data suggests contouring accuracy as good as doctors.
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Fancy a change in scene? Want to come and work
@royalmarsdenNHS
@ICR_London
with world leaders like
@PCaParker
(who wouldn't)? Come spend a year with us - gain experience on with MR-guided adaptive RT, SBRT (prostate and oligomets) plus systemic therapy.
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Wonderful day celebrating the awesome career of David Dearnaley
@ICR_London
A total legend in academic achievement, mentoring and patient care
@nickva1
@juliarmurray
@robert_huddart
@EmmaHall71
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Great to have Cyberknife in Sutton too now! Well done to the whole team.
First patient on Cyberknife at Sutton. Thanks to all those involved.
@royalmarsden
@royalmarsdenNHS
@fizzy_cyst
@nickva1
@sarah_helyer
@Accuray
@SCoRMembers
what a great team of rads and physicists
@PhilippaSturt
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Fantastic talk from
@robert_huddart
(on his birthday!) on the RAIDER trial
@ICR_CTSU
@royalmarsdenNHS
. Concomitant Gemcitabine associated with higher GI toxicity- important finding
#ESTRO2021
4
11
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Great to be at the
@Elekta
#MRLinac
consortium today.
@Shaista_Hafeez
presenting the
@royalmarsdenNHS
@ICR_London
experience of using the MR Linac in Bladder cancer - we hope this technology will improve local control and reduce side effects.
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I am going to try to stick to this for at least the next 5 minutes (thanks for finding it
@MellyB_7
!)
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First UK SABR/SBRT contouring course for new centres
@SABRconsortium
@RCRadiologists
@fifimcdrmh
telling us the who, why and how of lung SABR
7
11
53
Snatching victory from the jaws of failure, we had a great time at the
#OF20
Radiotherapy stream
@AthenaMeetings
listening to some fascinating talks from Neil Burnet,
@antheasaif
@NoraSundahl
and
@drdavidpalma
Radiotherapy is effective, under-utilised and so innovative.
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At last count, well under 10% of UK academic oncology spend went on radiation research. Imagine what we could do with 20%!
#voteradiotherapy
#radonc
@ICR_CTSU
@RM_Radiotherapy
In the second of our semi-finals, what do you think has been NCRI’s biggest achievement? Establishing the NCRI Groups or
#NCRI_CTRad
reinvigorating radiotherapy research?
#NCRI20
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Sincere thanks to
@KensingtonRoyal
for visiting
@royalmarsdenNHS
today to see the new MR Linac
#MarsdenMagic
#HRHvisit
@nickva1
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Great to see this amazing project starting to bear fruit, thanks to the leadership of
@lennyverkooijen
@whallradonc
and many others
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Excited to be en route to
#ESTRO23
! Looking forward to learning some new things and seeing many friends and colleagues.
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Come and spend a year working with us! 12 month fellowships now available. We offer experience in MR Linac, SBRT and systemic therapy (even for rad oncs!) UK or non-UK applications welcome
@juliarmurray
@AUPathmanathan
@PCaParker
@robert_huddart
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@nickva1
presenting the outcomes so far from the PACE trials. Radiotherapy now very well tolerated for vast majority of men, due to ongoing innovation radiotherapy. Much more to come yet!
@royalmarsdenNHS
@ICR_CTSU
@EmmaHall71
@Accuray
1
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Don’t miss this one! And the one after! (CHHiP 10 year data)
@ProfJOSullivan
@EmmaHall71
@ICR_CTSU
@royalmarsdenNHS
#GU23
Arrived in San Fran! Looking forward to presenting the
#PACE
-A results tomorrow at
#GU23
@alison_tree
@SbrtSean
@DrAndrewLoblaw
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Wow: Over 900 clinical trials currently recruiting
@royalmarsdenNHS
@ICR_London
@cancerBRC
, most involving international collaboration. This is how we make progress
Happy 1st December! 🎄
It's the first day of our research
#AdventCalendar
, celebrating all the clinical
#cancerresearch
happening at
@royalmarsdenNHS
@ICR_London
@cancerBRC
Find out more about our research portfolio behind door number 1 👇
#FutureofCancer
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Just advertised a new 2-year research fellow post- if you are interested in clinical radiotherapy research, MR-guided adaptive radiotherapy and would like to pursue an MD(Res), then please get in touch!
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Fantastic afternoon in the Houses of Parliament showcasing the exciting radiotherapy techniques which help us cure more cancer with less side effects
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Another great tweetorial! Men without acute toxicity much less likely to experience late toxicity after SBRT in PACE B. More work to come soon, defining the phenotype most likely to struggle with side effects- another step forwards in personalising dose constraints
🧵1/5. Here is our recent publication, analysing the association between acute vs late GU/GI toxicity following SBRT and CRT for localised prostate cancer: An analysis of the PACE-B study.
via
@Cancers_MDPI
@alison_tree
@nickva1
@EmmaHall71
@ICR_CTSU
2
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The first F2F
#MRlinacconsortium
in 3 years kicks off with
@whallradonc
. Remember there is a prize for the most liked tweet bearing the hashtag
#MRlinacconsortium
, so get tweeting!
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Best team in the world (might be a little biased)
@royalmarsdenNHS
@ICR_London
Team MRLinac
@royalmarsdenNHS
at the
@Elekta
MRLinac Consortium
#mrlinac
#unity
@alison_tree
@Gilly331
@Shaista_Hafeez
@fifimcdrmh
@AitkenKatharine
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1 year into oncology training, John asked me how I thought we should treat one of his breast patients. I hadn’t a clue but the fact that he was interested in my opinion was formative for me. Such a gifted and yet humble man
@royalmarsdenNHS
@ICR_London
Brilliant exposition from John Yarnold in his Claude Renaud medal talk. Reviewing a career of excellence in exploring fractionation. A well deserved honour
@ICR_CTSU
@royalmarsdenNHS
@ESTRO_RT
#ESTRO2021
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Great graphic from
@MRCCTU
showing the huge improvement in PFS and OS with the addition of Abiraterone in mHSPC (of any burden). So encouraging to see. Funding clinical research improves outcomes!
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Bored of watching Netflix in lockdown? Try this! Nice to have a virtual chat about radiotherapy with
@declangmurphy
@piet_ost
@_ShankarSiva
and
@RenuEapen
SBRT gurus
@_ShankarSiva
@piet_ost
@alison_tree
join GU Cast for a chat
#radonc
@SABRconsortium
@PeterMacRadOnc
Search GU Cast on your favourite podcast app
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Very reassuring 5 year bRFS with significant urethral sparing radiotherapy, and low rates of GU radiotherapy toxicity. Is this the way forward? Great work from
@ZilliThomas
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Seems appropriate on World Radiographers Day
#WRD2022
that I have just signed off another great radiographer to contour the prostate independently for MRIgART
@Elekta
Unity. So lucky to work with such a talented team
@RM_Radiotherapy
@treeherb
@H_A_McNair
@S0PHIEEA
@Yentl_hlc
2
9
47
Fantastic kick-off meeting for the
@CRUKresearch
Programme grant
@royalmarsdenNHS
@ICR_London
. We learned that margins are passé, biological targeting is the future and MR-guidance is key. Blue sky- diagnose and cure all cancer instantly with the “zap it” bus, made of Lego...
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Great work from
@RosalyneWestley
and
@S0PHIEEA
looking at feasibility of margin reduction with MRI-guided ART
#UKSABR2023
2
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Outstanding talk by
@lauren_henke
on progress in pancreatic SBRT. Much to be optimistic despite recent setbacks
#UKSABR23
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Inspiring talk from
@ethansgrumps
at
@ICR_London
today. Exercise is fundamental to maintaing QOL for men with PCa, yet a supported exercise programme not routinely and consistently available across the UK. We need to change this!
Great privilege to have
@ethansgrumps
,
@ProstateUK
Ambassador, speaking to us here at
@ICR_London
today! He's on our
#Sutton
site where some of the world's leading
#ProstateCancer
research is happening.
Thank you
@AdamSharpMedOnc
for hosting!
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I’m still in denial! Very sad day for us, but the most well deserved retirement. What a legacy of work and total legend all round
@juliarmurray
Professor Dearnaley has taught us all so much! It’s time for us to carry on his legacy. Good thing he’s taught so many thought leaders:
@PCaParker
@Prof_Nick_James
@nickva1
@alison_tree
and many more!
#StandOnTheShouldersOfGiants
#pcsm
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Fascinating, thanks. I have been saying for years that Stanford delivered the first modern radiotherapy treatment but it appears that Constance Wood treated patients in London from 1953. Maybe I should revise my standard slide set!
History lesson: Constance Wood was a towering figure of
#radonc
but sometimes forgotten today. She was first director of MRC Radiotherapy, & with physicist Louis Gray, the first to use clinical linac and cyclotron, at Hammersmith UK. She changed cancer tx forever.
#WomenWhoCurie
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Agree- this is the future!
@RCRadiologists
What an amazing editorial format. RAPIDO trial excellent analysis👏👏👏. Don't loose it
#radonc
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@TylerSbrt
I don’t use spacers (pending larger trials): 1.6% G2 toxicity at 2 years in PACE B without spacers and absence of effect on acute tox in the RCT of spacers with 2Gy/ frac doesn’t fill me with enthusiasm for putting the patient through another procedure.
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Important data below👇 We can make clinical trial follow up less onerous for patients, without compromising data quality. Well done
@ICR_CTSU
for spotting an opportunity to answer an important question.
Looking at PIVOTALboost, PACE-B and PACE-C, we found that asking our NHS colleagues to use phone calls during the pandemic instead of continuing in person clinic visits had minimal impact on data quality.
@EmmaHall71
,
@nickva1
,
@alison_tree
. Abstract here:
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A randomised trial in penile cancer, itself the very definition of unmet need. If you can support this trial, please do get in contact with the
@ICR_CTSU
- we would be delighted to have you on board.
InPACT is a
#clinicaltrial
investigating the optimal treatment for locally advanced
#penilecancer
. We work with
@eaonc
on InPACT, and it is funded by
@SU2CUK
. Read more on our website: or the
@CRUK
lay summary: .
#RareDiseaseWeek
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Please read this open letter from key opinion leaders in radiotherapy. Hoping there will be a solution which enables more patients to benefit from
MRIgART and continues the excellent research that the MRIdian community have given to our field.
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Fantastic presentation by
@juliarmurray
presenting DELINEATE 5 fraction boost; similar G2 toxicity to PACE B, but some Grade 3 toxicity. Need to focus on putting dose where it matters most and drop dose where it can cause side effects. Thanks to JP Moulton foundation for support
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