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Living well, with and beyond
cancer: The evidence
25 September 2014
Welcome and introduction
The Royal Marsden
What should you eat after
cancer treatment?
Clare Shaw PhD RD
What should you eat after cancer treatment?
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The Royal Marsden
What should you eat after cancer treatment?
Overview
– What happens to nutritional status and food intake during
cancer treatment?
– Nutritional issues after cancer treatment?
– What is the ideal diet?
– Does diet make a difference to the risk of cancer
recurring?
– What about ‘Superfoods’?
– Summary
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What should you eat after cancer treatment?
What happens to nutrition during cancer treatment?
– Rates of malnutrition are higher in people with cancer
– Malnutrition can occur due to
– Reduced food intake
– Metabolic changes due to cancer
– Side effects of treatment
– Importance of addressing nutrition
to provide optimal care
(NICE guidance, CQC, British Dietetic Association)
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What should you eat after cancer treatment?
Nutritional status
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–
–
–
1000 patients nutritionally screened, all diagnoses
40% had lost more than 10% of body weight
34% identified as severely malnourished
Poor nutritional status associated with upper Gastro
Intestinal cancers, advanced disease and poor
performance status
– Bozzetti (2009) Supportive Care in Cancer
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What should you eat after cancer treatment?
Royal Marsden
Nutritional status of inpatients, 2012-13
128 patients
Category
Count (percentage) of patients within each category
PG-SGA
RMNST
MST
Well nourished
36 (29)
25 (20)
[score: 0 - 4]
61 (48)
[score: 0 - 1]
Moderately nourished
63 (50)
33 (26)
[score: 5 - 9]
-
-
-
65 (52)
[score: 2+]
27 (21)
68 (54)
[score: 10+]
-
Malnourished
Severely malnourished
71% of patients at medium or high risk of malnutrition
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What should you eat after cancer treatment?
Symptoms – increase risk of weight loss
Symptom
No appetite
Early satiety
Pain
Taste changes
Nausea
Dry mouth
Constipation
Vomiting
Diarrhoea
Problems swallowing
Smells bother me
Mouth sores
Khalid et al, 2007
Percentage (%)
38
27
23
20
18
17
14
11
11
9
7
1
• Subjective Global Assessment
• 151 new patients (Lung and GI)
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What should you eat after cancer treatment?
What about weight gain?
– Some people may gain weight during chemotherapy
– 98 women with breast cancer in USA (Sheppard et al, 2013)
– 62% maintained weight
– 29% gained weight (more than 5% of their baseline weight)
– 9% lost more than 5% of pre treatment weight
– 98 women with breast cancer in China (Wang et al, 2014)
– Weight changes from – 11 kg to + 9 kg
– 67% gained more than 1 kg
– 4561 women with breast cancer (Chen et al, 2011)
– 61% gained weight 18 months after treatment for breast cancer
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What should you eat after cancer treatment?
It is not only breast cancer patients
– Prostate cancer patients undergoing chemotherapy
(Joly et al, 2010)
– 50% gained weight
– Prostate cancer patients on Androgen-deprivation therapy
(ADT) (Kim et al, 2011)
– 132 men, 92 (70%) gained weight and 40 (30%) either
lost or maintained a stable weight
– Weight gain after a diagnosis of prostate cancer is
associated with an increased rate of prostate cancer
specific mortality (Bonn et al, 2014)
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What should you eat after cancer treatment?
What to eat during cancer treatment?
– Good balanced diet providing all the required nutrients
– Balance of protein, fat and carbohydrate and total energy
may change depending on requirements
– Weight loss
– Weight gain
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What should you eat after cancer treatment?
Recommendations after cancer
treatment
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Make a Change, Live
What
Wellshould you eat after cancer treatment?
World Cancer Research Fund UK
Recommendations
1.
2.
3.
4.
5.
6.
7.
8.
9.
Be as lean as possible without becoming underweight
Be physically active for at least 30minutes every day
Avoid sugary drinks and limit the consumption of high calorie foods
Eat more of a variety of vegetables, fruits, whole grains and pulses
Limit intake of red meat and avoid processed meat
Limit alcoholic drinks to 2 a day for men and 1 a day for women
Limit consumption of salty foods
Do not use nutritional supplements to protect against cancer
After treatment, cancer survivors should follow the
recommendations for cancer prevention
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Make a Change, Live
What
Wellshould you eat after cancer treatment?
Aim to be a healthy weight
– Aim for a healthy weight for
your height
– BMI 20 – 25 kg/m2
– Aim for a healthy waist
measurement
– Less than 31 ½ inches/80cm
for women
– Less than 37 inches/94cm
for men
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What should you eat after cancer treatment?
www.wcrf-uk.org
The Royal Marsden
Is this the right diet for
everyone?
What should you eat after cancer treatment?
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Gastrointestinal symptoms as
a result of cancer treatment
What should you eat after cancer treatment?
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What should you eat after cancer treatment?
Gastro-intestinal Symptom Rating Scale: 12
months (following chemo/RT/surgery
Most common at 12 months (n=25)
% patients
Flatulence
76%
Belching
72%
Abdominal pain
68%
Abdominal grumbling
56%
Early satiety
52%
Acid reflux
48%
Incomplete evacuation
48%
Constipation
44%
Diarrhoea
44%
Upper gastrointestinal cancer patients
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What should you eat after cancer treatment?
GI problems following pelvic radiotherapy
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What should you eat after cancer treatment?
Consequences of cancer treatment clinic
Profile of patients
Cancer site
Urology
Gynaecology
Colorectal
Upper GI
Haematology
Other
Prevalence in our clinic
population (%)
37%
prostate: 88%
18%
cervix: 51%
16%
rectum: 48%
12%
gastric: 46%
6%
multiple myeloma: 46%
11%
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What should you eat after cancer treatment?
% of patients with moderate or severe
GI symptoms (n=110)
noct defaecation
steatorrhoea
rectal bleeding
heartburn
nausea
leakage
tenesmus
severe
moderate
diarrhoea
frequency
urgency
borborygmi
belching
flatulence
bloating
abdo pain
0
10
20
30 40 50 60
% of affected patients
70
80
90
100
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The Royal Marsden
What should you eat after cancer treatment?
Nutritional consequences of cancer treatment
– Weight change
– Weight loss
– Weight gain
– Gastrointestinal symptoms
– Pelvic radiotherapy
– Upper GI surgery
– Bone marrow transplantation
– Swallowing problems
– Head and neck patients
– Taste changes
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The Royal Marsden
What should you eat after cancer treatment?
Does a healthy diet make a
difference to the risk of cancer
returning?
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What should you eat after cancer treatment?
Women’s Healthy Eating and Living Study (WHEL)
– Recruited women with breast cancer, on average, 23.5
months post diagnosis
– 3088 women
– Randomised
– Counselling programme to increase 5 portions
vegetables and 3 portions of fruit plus 16 oz vegetable
juices plus a reduction in fat intake
– Control group – written material on eating ‘5 a day’
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What should you eat after cancer treatment?
The Women’s Healthy Eating and Living Randomized Trial
Pierce et al, 2007
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What should you eat after cancer treatment?
Risk in women taking tamoxifen
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What should you eat after cancer treatment?
WINS study
– 2437 women with breast cancer reduced their fat intake
from 51g to 33g
– Lost on average 6lb in weight
– Follow up period of 60 months
– Measured relapse of breast cancer
Chlebowski et al, 2006)
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What should you eat after cancer treatment?
WINS study
Oestrogen
receptor
positive
Oestrogen
receptor
negative
Chlebowski et al, 2006)
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What should you eat after cancer treatment?
What about Superfoods?
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What should you eat after cancer treatment?
What is a Superfood?
– Substance that is liked by the popular press!
– Claimed to have special health giving beneficial properties
– Much interest in individual foods and cancer risk
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Superfoods?
What should you eat after cancer treatment?
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The Royal Marsden
What should you eat after cancer treatment?
Superfoods?
– Often lack the scientific evidence to support ‘ popular
claims’
– Often delicious and great to include as part of a balanced
diet
– Variety is perhaps the most important aspect, especially
fruit and vegetables.
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What should you eat after cancer treatment?
Summary
– Variety of nutritional issues at the end of treatment
– May be consequences of treatment
– Body weight – very important! (especially hormone
dependent cancers)
– Superfoods – eat them (but don’t expect too much!)
– Healthy eating guidance for those who are eating well
Dietary advice after cancer, the
reality
Ms Rebecca Shoosmith
Evidence based smoking
cessation intervention in head
and neck cancer
Mr Richard Oakley
Consultant Head and Neck Surgeon
Guy’s and St Thomas’ NHS Foundation Trust
Coffee Break
Please spend some time looking at the marketplace as well as ‘networking’
The evidence for exercise
throughout the cancer pathway
Nicola Glover
BSc (Hons), PGCert, MCSP
The London Cancer Alliance West and South
Overview
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Definitions
Rehabilitation and survivorship models
Behavioural change
Overview of the evidence
– Summary by pathway point
– Specific examples
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Risk assessment and considerations
International recommendations
UK guidelines
Summary
The London Cancer Alliance West and South
Exercise or physical activity?
• Exercise:
“activity requiring physical effort, carried out to sustain or improve
health and fitness”
Oxford English Dictionaries (2014)
• Physical activity:
“Physical activity is defined as any bodily movement produced by
skeletal muscles that requires energy expenditure”
World Health Organization (2014)
The London Cancer Alliance West and South
Cancer rehabilitation
• Preventative: reducing impact of expected disabilities
and improving coping strategies
• Restorative: returning person to pre-morbid levels
• Supportive: in presence of persistent disease and need
for treatment, rehab is aimed at limiting functional loss
and providing support
• Palliative: prevent further loss of function, measures put
in place to eliminate or reduce complications and to
provide symptom management
(Dietz 1980)
The London Cancer Alliance West and South
Physical activity and cancer control model
Peace framework, Courneya and Friedenreich (2001), from ACSM (2010)
The London Cancer Alliance West and South
Teachable Moment
• Something happens which means that you are open to
change
• Have to recognise that change is necessary
• Have to understand that life-style behaviours are
impacting on health (BeWEL programme, Anderson et al 2014)
• Have to believe you can make the change
• Self-determination and self-efficacy (Bandura 1977)
• Transtheoretical model (Prochaska 1977)
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Pre-contemplation
Contemplation
Preparation
Action
Maintenance
The London Cancer Alliance West and South
Evidence for exercise during treatment
• Safe and feasible
• Improves physical function (17 RCTs), fatigue(15 RCTs)
and quality of life (10 RCTs)
• May increase the completion of chemotherapy
• Reduces on-treat side effects e.g. pain, nausea
• Improves multiple post-treatment effects
– Bone health
– Muscle strength
• Reduces length of stay
• Increases immune function
• Increases strength and lung function
Baumann et all (2010), Schmitz et al (2010), Macmillan, Spence et al (2009), Grimmet (2011), Speck (2010), Dimeo (1997)
The London Cancer Alliance West and South
An update of controlled physical activity trials in
cancer survivors: a systematic review and metaanalysis (Speck et al 2010)
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66 studies with high internal validity
Physical activity
Aerobic fitness and upper and lower limb stranght
% body fat
Functional quality of life
Mood, anxiety, self-esteem
Only 5 adverse incidents attributable to exercise
Recurrent themes of fear of harm, specifically around
exercise towards end of treatment, with lymphoedema
(risk) and with neutropaenia
• On-going advice to ‘take it easy’
The London Cancer Alliance West and South
Post-treatment
• Significant improvements in VO2 Max, upper and lower
body strength, resting heart rate (breast)
• Higher levels of physical activity = ↑ QoL, physical
functioning and fatigue (CRC)
• Systematic reviews show positive effects on muscular
fitness, physical functioning, fatigue and HR QoL (prost)
• RCT of 121 people having RT +/- ADT showed aerobic
improved fatigue and fitness and resistance training
showed fatigue, QoL, aerobic fitness, strength (prost)
• Progressive resistance training reduces lymphoedema
recurrence
• Reduced fatigue (14 RCTs)
Macmillan, Spence et al (2009)ACSM (2010), Baumann et al (2010) Dimeo (1997, 2008), Buffart et al (2013)
The London Cancer Alliance West and South
Evidence-based physical activity guidelines for cancer
survivors: current guidelines, knowledge gaps and
future research directions (Buffart et al 2013)
• Widespread, consistent evidence that exercise is safe
and sedentary lifestyle should be avoided
• Should be working at 80% 1-RM and 50-80% HR max
• Aerobic exercise improves VO2 max and prevents fat
gain
• Resistance training improves lower and upper body
strength and adds lean mass
• Both alter body composition, but not weight
• Both alter psychosocial outcomes
The London Cancer Alliance West and South
Limitations to research
• Most gold standard evidence remains within breast,
colorectal, prostate and SCT
• Dose remains unclear
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How much?
How often?
What?
When?
The London Cancer Alliance West and South
Risk assessment
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Increasing co-morbidities
Bone mets?
Lymphoedema?
Tumour specific limitations?
• Use of assessment tools, such as PAR-Q+
Warburton et al (2011), Burr et al (2012)
• Do we know what ‘safe’ is?
The London Cancer Alliance West and South
Secondary prevention and reduced all-cause
mortality and morbity
• Meta-analysis including more than 12,000 survivors
– Post-diagnosis physical activity associated with a 24% lower
cancer recurrence and 34% lower breast cancer mortality and a
41% lower all cause mortality
• ↓ cancer recurrence, colorectal mortality and all cause
mortality
• In women, 50% all cause mortality reduction with
>9MET/h/wk
• Post-SCT, reduced serious infections, increased recovery
and faster discharge
(Anderson et al 2014)
(Mayerhardt et al 2006 in Grimmett 2011)
The London Cancer Alliance West and South
LUNGEVITY (Jones et al 2010)
• Single centre RCT with 4
arms
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Aerobic training
Resistance training
Combination
Attention control
• Multiple analysis
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VO2 max
PRQoL (FACT-L and
depression scale))
FEV1 and Cardiac output
Hb concentration
Muscle Fibre distribution
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Adults
6 months post surgery
Karnofsky of at least 70%
Regular exercise (> 5/7, >30
mins)
The London Cancer Alliance West and South
International Recommendations
“Existing evidence strongly suggests that exercise is not only safe and
feasible during cancer treatment, that…it can improve physical
function, fatigue, and multiple aspects of quality of life”
American Cancer Society (2012)
“…both aerobic and resistance exercise [should] be prescribed, unless
specific problems dictate otherwise.”
Australian Association of exercise and sport science (2009)
“…cancer survivors should follow the 2008 Physical Activity Guidelines
for Americans…the advise to “avoid inactivity”…is likely helpful.”
American College of Sports Medicine (2010)
“An overall volume of 150 mins of moderate-intensity exercise, or 75
mins vigorous-intensity exercise of an equivalent combination.
Guidelines for strength training is to perform two or three weekly
sessions that include exercise for major muscle groups. Flexibility
guidelines are to stretch major muscle groups and tendons on days that
other exercise are performed.”
US Department of Health and Human Services (2008)
The London Cancer Alliance West and South
UK Recommendations
• “Unless advised otherwise, cancer survivorship should follow the
health-related physical activity guidelines for the general UK
population”
British Association of Sport and Exercise Sciences (2011)
• “Cancer survivors should be advised to gradually build up to the
health-related physical activity guidelines for the general
population.”
Macmillan
• “At least 150 minutes of moderate-intensity aerobic activity…and
muscle strengthening activities on two or more days…or 75 mins of
vigorous-intensity aerobic activity…and muscle-strengthening
activity on two or more days a week”
www.nhs.uk physical activity guidelines for adults (2014)
The London Cancer Alliance West and South
Conclusions
• Evidence is overwhelming suggestive that exercise at
high intensities is safe throughout the cancer pathway
• Risk assessment is important
• Referral to cancer trained exercise specialists is
sometimes useful
• Consider referral to oncology specialist physios for those
with complex presentations/multiple morbidities and/or
higher risk factors for exercise
The London Cancer Alliance West and South
Take home message
Avoid a sedentary lifestyle. Some exercise is better
than none, and more is better than less, at least up
to recommended amounts.
Supporting Return to Work
following Cancer Treatment
Theresa Wiseman
Lead for Health Service Research,
The Royal Marsden
Amrit Sangha
Research Assistant, The Royal Marsden
The London Cancer Alliance West and South
Background
• It is estimated that there are approximately 700,000
people of working age with cancer in the UK (Maddams et
al. 2009).
- This figure is increasing in line with people working
later in life.
- People with cancer are 1.37 times more likely to be
unemployed than those without (de Boer et al. 2009).
The London Cancer Alliance West and South
Background
• Work serves a range of functions reducing or avoiding:
- social isolation
- boredom
- loss of self-esteem
- financial hardship
• It is also a way of enabling people to regain normality,
self-concept and identity.
(Amir et al. 2008, Spelton et al. 2002 & Frazier et al. 2009)
The London Cancer Alliance West and South
Background
• Between 20-30% of people report impairments in ability
to work after cancer (Taskila et al. 2007).
• Many who do return to work report:
- a loss of self-confidence
- difficulty coping with symptoms at work
- feeling less able to do their jobs
- deteriorating career prospects
(Lee et al. 2008, Main et al. 2005 & Bennett et al. 2009)
The London Cancer Alliance West and South
Research Groups
• There is a growing number of multi-disciplinary research
groups focused on cancer and work.
• CCAT- 12 researchers including Prof Mary Wells, Dr
Diana Greenfield & Dr Theresa Wiseman
• CanWork (UK)- 13 researchers including Theresa
Wiseman
• CANWON Network (Europe)- connects 28 researchers
from 18 EU countries
• Work Foundation
• Vocational Rehabilitation- Dr Gail Eva
The London Cancer Alliance West and South
CANWON
• CANWON Network (Europe): 4 work streams
1. Prognostic factors of work participation in cancer
survivors
2. Work-related costs of survivorship
3. Role of employers
4. Development and evaluation of innovative,
interdisciplinary interventions
The London Cancer Alliance West and South
CANWON
• 1. Prognostic Factors
What we know:
• Fatigue, Depression
• Cognitive functioning, Work ability
• Diagnosis and Treatment
What we need to explore:
• Gender issues
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Social security systems and legislation
Cultural differences
Validated and reliable instruments
Harmonisation of new quantitative data collection
The London Cancer Alliance West and South
CANWON
• 2. Work-related Costs
What we need to explore:
– Economic consequences of decreased work participation:
unemployment, unpaid sick leave, reduced productivity and
income losses, early retirement.
– Effect of social policies and macro-economic situation
• What we will aim do:
– Assess transitions from employment to unemployment, sick
leave, lower income and reduced productivity
– Calculate the cost of all detrimental effects of cancer upon the
occupational status
The London Cancer Alliance West and South
CANWON
• 3. Employer
What we need to explore more:
– Accommodating role of employers and line managers
– Discrimination
– Social security systems and legislation
• What we will do:
• Study communication on work participation matters
• Assess workplace factors such as workplace accommodations
(such as change of work times, adaptations of physical
workplace and travel arrangements).
• Discrimination of cancer survivors in work participation
• Social policies and the role of the employer
The London Cancer Alliance West and South
CANWON
4.Interventions
• What we know:
– Return to work of cancer patients needs to be supported
• What we will do:
– Establish a theoretical model
– Development new multidisciplinary interventions, adapted to
identified prognostic factors and social legislation and role of
employer
– Use knowledge of earlier and running interventions
– Evaluate cost-effectiveness of these new interventions in
controlled trials and field studies
The London Cancer Alliance West and South
REJOIN study
NIHR Post-Doc Fellowship - Dr Gail Eva
- Priority to provide services to support patients’ to return
to work.
- Very little research which assesses the effectiveness of
vocational rehabilitation.
- Study aims to determine the feasibility of a RCT to
evaluate a cancer-specific vocational rehabilitation
intervention (the REJOIN intervention) in terms of its
clinical and cost effectiveness.
The London Cancer Alliance West and South
Return to Work - Perspectives from the workplace
Dr Theresa Wiseman
• Grounded theory study
• Interviewing people returning to work and managers
facilitating return to work
• 17 participants, 12 RTW, 5 managers
Within
ORGANISATION
Within
MANAGER
Within
SELF
The London Cancer Alliance West and South
Wells et al. 2013
- Conducted a systematic review and meta-synthesis of
the qualitative literature on employment and cancer.
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Individuals experiences of “return to work” were
strongly influenced by 4 key factors.
The London Cancer Alliance West and South
Model
Wells et al. 2013
The London Cancer Alliance West and South
1. Self-identity
• Re-establish a sense of their former selves.
- Maintain their identity as a reliable and useful
employee.
- Opportunity for growth and self-development.
- A way of confronting and re-adjusting to their altered
bodies.
- However some felt that others saw them differently,
which fuelled their own negative self-perceptions.
The London Cancer Alliance West and South
2. Meaning and significance of work
• Work viewed as providing a structure to everyday life
and being a source of social interaction.
• The disruption or loss of this structure could threaten
survivor’s well-being causing:
– financial burden
– dislocation from normal life
– loss of the self-esteem and social interactions gained through
working life
The London Cancer Alliance West and South
2. Meaning and significance of work
• For many the “old normality” was rarely achieved.
• Negative work experiences appeared to be heavily
influenced by colleagues or managers perceived
attitudes and behaviours.
• The importance of work diminished in relation to family
and personal pursuits.
• Survivors with fears of recurrence felt frustrated about
spending their time working, rather than pursuing other
goals.
The London Cancer Alliance West and South
3. Family and financial context
• Cost associated with cancer pushed some survivors into
remaining in particular work roles.
• Some choose to go back to protect their position at work
or provide for lifestyle aspirations.
• Attitudes towards benefits systems were mixed:
– some reporting systems fair, accessible and easy to negotiate
– others reporting insensitive treatment, protracted claims and
administrative errors
The London Cancer Alliance West and South
3. Family and financial context (2)
• Attitudes of family members could sometimes have a
negative effect on self-confidence. Which could be seen
as:
- overly supportive or protective
- disapproving of return to work
- suggesting that survivors should expect
exactly the same conditions as before
The London Cancer Alliance West and South
4. Work environment - relationships and
performance
• Positive experiences of returning to working were
dependent on:
- good organisational & work related support
- and/or interpersonal support
• Successfully returning to work depended on:
- the kind of job e.g. manual or professional
- the physical and emotional demands of the role
- the size of the organisation
The London Cancer Alliance West and South
4. Work environment - relationships and
performance
• Adjustments in the workplace such as:
- modifications to the workplace
- working hours
- duties
- accommodation of hospital appointments
- load alleviation
- provision of assistance and changes in personnel
The London Cancer Alliance West and South
4. Work environment - relationships and
performance
• Healthcare professionals frequently failed to meet the
needs of survivors.
• Some felt they were “bothering” their doctor or simply
did not know what to ask.
• Many organisations lacked HR personnel specific to
dealing with survivors.
• Occupational health wellness programmes were seen as
beneficial but were usually only available in larger
organisations.
The London Cancer Alliance West and South
Responses and strategies
• Survivors appeared to use 4 strategies to help them
integrate into work after cancer:
1. Communication and negotiation with employers
2. Acknowledging and accepting changed capabilities
3. Managing symptoms and rebuilding confidence
4. “Working Smarter”
The London Cancer Alliance West and South
Responses and strategies
1. Communication and negotiation with employers
- Some survivors were reluctant to disclose their cancer
diagnosis with employers. Whilst others believed in open
communication.
2. Acknowledging and accepting changed capabilities
- Successful self-management of symptoms and utilisation
of supportive resources.
- Some felt frustrated which led to feeling overwhelmed as
they struggled to manage symptom and work demands
The London Cancer Alliance West and South
Responses and strategies
• 3. Managing symptoms and rebuilding confidence
Important in rebuilding self-confidence and feelings of
reliability at work.
Strategies for managing fatigue and cognitive problems
included:
- checking work with colleagues
- keeping more detailed records
- reducing self-expectations.
The London Cancer Alliance West and South
Responses and strategies
4. “Working Smarter”
- pacing themselves/resting at work
- taking days off when necessary
- managing time
- giving themselves flexibility
- concentrating on tasks that best utilised their strengths
The London Cancer Alliance West and South
Points to consider
- Returning to work is rarely seen as an end in itself.
- Need to acknowledge individuals sense of identity as well
as the meaning and significance of work.
- Urgent need to develop new strategies or policies.
- Initiatives should focus on supporting “work-related
goals” rather than assuming the desirability of return to
work.
The London Cancer Alliance West and South
Future role
- Clinical team managing the patient can have a key
influence on the likelihood of patients returning to work
(Pryce et al. 2007).
- Need to implement support into clinical practice.
- Front line oncology staff need to be open to dialogue
around returning to work.
- Nurses can play a key role in signposting to further advice
and support.
The London Cancer Alliance West and South
Further work
• Further longitudinal research is also needed:
- on the experiences of individuals over time
- the perspectives of under-researched groups
- those who are self-employed or do not return to work
- people with advanced disease
- family members
- employers
The London Cancer Alliance West and South
Thank you
[email protected]