Kathy’s Story: Living Better with Mesothelioma – Possible with the Right Team of Experts

Kathy Ebright was enjoying life with her husband, 2 kids and 7 grandchildren in rural Pennsylvania, when everything changed suddenly.  This is true for thousands of people fighting cancer across the world, but hearing the word “mesothelioma” is not common.

“I went numb, I might have said a few words, but I couldn’t put words together to speak,” Kathy said.

Kathy and her husband, Doug

Almost everyone has been touched by cancer, but Kathy and her husband didn’t know anyone with mesothelioma in their small town of Richfield. They only heard of the disease from commercials for lawyers who specialize in asbestos lawsuits.

Kathy’s mesothelioma was discovered during a scan of her abdomen, which she has regularly to monitor a heart condition.  Her vascular doctor saw unusual spots on her scans, which her primary care doctor and oncologist reviewed, and they determined it was pleural mesothelioma.  This means the cancerous cells are located in the chest cavity, and sometimes the lung.  Usually, those with pleural mesothelioma experience shortness of breath, but Kathy was lucky enough to catch her mesothelioma before experiencing any symptoms.

Kathy’s daughter, Ally, who works with the tumor registry at the Geisinger Medical Center, sprang into action after the initial shock.  They attended tumor boards at Geisinger, where physicians from multiple disciplines (radiation, medical, and surgical oncology) meet to discuss cases.  Kathy’s medical oncologist, Dr. Rajiv Panikkar, suggested to Kathy that she go to the University of Maryland Greenebaum Comprehensive Cancer Center in Baltimore, where she would see a team skilled and experienced in the most novel treatments for mesothelioma.

On December 20, 2015, about a month after her initial diagnosis, Kathy had her first appointment with Dr. Joseph Friedberg, a nationally known expert in mesothelioma and head of thoracic surgery at the University of Maryland Medical Center.

Kathy and her family were nervous, but mesothelioma nurse navigator Colleen Norton helped them navigate the unfamiliar and frightening process of a mesothelioma diagnosis.  She made sure they were prepared for their appointment beforehand, and Colleen even handled authorization with their health insurance company.

“We just felt we were along for the ride because Colleen always had everything taken care of,” said Kathy’s husband Doug.

And they were just as impressed with Dr. Friedberg, who was calm, reassuring and explained Kathy’s situation very clearly.

“On the back of his folder, he hand drew a lung to display what was going on with me, and it could’ve been taken right from a textbook it was so good,” Kathy said.

Kathy’s granddaughter, Carleigh, who serves as her main cancer-fighting motivator

They were also impressed with Dr. Friedberg’s tenacity and understanding.  Kathy wanted to spend Christmas with her family, but Dr. Friedberg didn’t want wait too long to perform the lung sparing surgery.

Her surgery was scheduled for January 5, 2016.

Throughout the surgery, Kathy’s family couldn’t have been more comfortable and informed.

“We camped out in the Healing Garden just about the entire time,” Doug said. “Melissa Culligan, Dr. Friedberg’s nurse, was in and out of the operating room, updating us every two hours.  We were never left wondering how Kathy was doing.  We also had the option to call into the operating room if we had any questions.”

During Kathy’s recovery in the hospital, she said the nurses were “phenomenal.”  Colleen also came to see her several times a day, and they added a La-Z-Boy to Kathy’s room so her husband could more comfortably spend the nights with her.

While there is no cure for mesothelioma, yet, Kathy and her family couldn’t be happier to have the UMGCCC team in their corner.  She now returns every 3 months for the next 2 years for check-ups, and Dr. Friedberg describes her scans as “pristine.”

“It’s very reassuring to know we have such caring people looking out for my health,” Kathy said.

Learn more about the Mesothelioma and Thoracic Oncology Treatment Center at the University of Maryland Marlene and Stewart Greenebaum Comprehensive Center by clicking here, or calling 410-328-6366.

Protect Your Skin This Summer

By Kirsten Bannan, System Communications Intern

As the summer progresses the initial sunburn has faded and it’s time to think about protecting your skin. Everyone wants that bronze glow that comes with a summer tan, but most people are sun picnot aware of the damage the sun can cause to your skin and your health. Here are some facts and tips that will help you protect your skin this summer.

Skin Cancer is the most common cancer in the United States. Most skin cancers are caused by exposure to Ultraviolet (UV) rays. The sun emits these rays and you can get extra exposure from using tanning beds or sun lamps. “People who use tanning salons are 2.5 times more likely to develop squamous cell carcinoma, and 1.5 times more likely to develop basal cell carcinoma. According to recent research, first exposure to tanning beds in youth increases melanoma risk by 75 percent” (Skin Cancer Foundation). There are two types of UV radiation that affect the skin: UVA and UVB. Both kinds of rays can cause skin cancer, weaken the immune system, contribute to premature aging of the skin, and cataracts (See our Cataract Awareness Article).

UVA Rays– they are not absorbed by the ozone layer and penetrate skin to contribute to premature aging. “They account for up to 95 percent of the UV radiation reaching the Earth’s surface” (Skin Cancer Foundation). UVA is the prevalent tanning ray; tanning itself is actually damage to the skin’s DNA. The Skin gets darker in an attempt to protect from further DNA damage.

UVB Rays– they are partially absorbed by the ozone layer and are the primary cause to sunburn. They play a very large role in the development of skin cancer. The most intensive UVB rays hit the Earth around 10am to 4pm from April to October.

There are protective measures that you can take to prevent against damage and skin cancer. Since the sun can damage your skin in as few as 15 minutes, it’s important to put sunscreen on when you know you will be outside for an extended period of time. Sunscreen works by absorbing, reflecting, or scattering sunlight. They contain chemicals that interact with the skin to protect it from UV rays.
Here are some other tips from the Centers for Disease Control and Prevention on sun safety:

A wet T-shirt offers much less UV protection than a dry one, and darker colors may offer more protection than lighter colors.

A regular T-shirt has an SPF rating lower than 15, so use other types of protection as well.

Sunglasses protect your eyes from UV rays and reduce the risk of cataracts. They also protect the tender skin around your eyes from sun exposure.

o Sunglasses that block both UVA and UVB rays offer the best protection. Most sunglasses sold in the United States, regardless of cost, meet this standard. Wrap-around sunglasses work best because they block UV rays from sneaking in from the side.

SPF. Sunscreens are assigned a sun protection factor (SPF) number that rates their effectiveness in blocking UV rays. Higher numbers indicate more protection. You should use a broad spectrum sunscreen with at least SPF 15.

Reapplication. Sunscreen wears off. Put it on again if you stay out in the sun for more than two hours and after swimming, sweating, or toweling off.

Cosmetics. Some makeup and lip balms contain some of the same chemicals used in sunscreens. If they do not have at least SPF 15, don’t use them by themselves.

Sunscreen is one of the best ways of protecting yourself from the sun’s harmful rays. Make sure to get a sunscreen that protects against UVA and UVB rays. Sunscreen labels that have “Broad Spectrum” means they protect against both kinds of rays. You also want to make sure to know the difference between “water resistant” and “waterproof”. The American Cancer Society says that “No sunscreens are waterproof or “sweat proof,” and manufacturers are no longer allowed to claim that they are. If a product’s front label makes claims of being water resistant, it must specify whether it lasts for 40 minutes or 80 minutes while swimming or sweating”. They recommend reapplying every two hours and even sooner if you are sweating or swimming.

No matter what summer activities you have planned this summer, make sure you protect your skin from the sun’s harmful rays. It takes 2 minutes to apply sunscreen and that can help save you from a lifetime of skin damage or even skin cancer.

Take a Sun Safety IQ Quiz from the American Cancer Society:
http://www.cancer.org/healthy/toolsandcalculators/quizzes/sun-safety/index’

Sources:
http://www.cdc.gov/cancer/skin/basic_info/sun-safety.htm
https://www.epa.gov/sites/production/files/documents/sunscreen.pdf
http://www.cancer.org/cancer/cancercauses/radiationexposureandcancer/uvradiation/uv-radiation-avoiding-uv
http://www.cancer.org/cancer/news/features/stay-sun-safe-this-summer
http://www.skincancer.org/prevention/uva-and-uvb

Safe Firework Fun

FireworkSafetyBy Kirsten Bannan, System Communications Intern

Summer is in full swing and as the temperature increases, so does the amount of summer events happening. The 4th of July is right around the corner and everyone knows it is a popular holiday to spend time with family and friends and enjoy some summer traditions such as fireworks.

Sometimes holiday fun is not as harmless as you might think. Even though fireworks seem like a safe and fun way to spend the holiday, “230 people on average go to the emergency room with firework-related injuries in the month around the July 4th holiday” (US Consumer Product Safety Commission).

A sparkler, popular to most at-home firework displays, can heat up to about 1,200 degrees Fahrenheit, which can cause serious burns especially if in the hands of children. Kids aren’t the only ones who need to be careful; the age group most susceptible to injuries by fireworks is the 20-40 age groups which are usually the age group responsible for lighting fireworks at home. Sometimes the influence of alcohol can contribute to high numbers of injury during at- home firework displays.

Karen Hardingham RN, BSN, CPST Safe Kids Baltimore Coalition Coordinator has some helpful tips for those who still want to include fireworks in their 4th of July experience. She is most adamant about attending professional firework displays rather than at-home shows. She says, “leave it to the professionals, do be aware of labels and laws of the area, and look at alternatives.”

Some events in the Baltimore area to attend are as follows:

  • Baltimore’s Fourth of July Celebration presented by Ports America Chesapeake
    Location: Baltimore Inner Harbor, 561 Light Street, Baltimore, MD 21202
  • Fullerton Park
    Location: 4304 Fullerton Avenue, Baltimore 21236
    Rain Date: July 5
  • Loch Raven Academy
    Location: 8101 Lasalle Road, Towson 21286
    Rain Date: July 5
  • Catonsville High School
    Location: 421 Bloomsbury Avenue, Catonsville 21228
    Rain Date: July 9

For a full list of public firework displays in Maryland click here.

If you are determined to have an at-home firework show, consider substituting hand-held sparklers with glow sticks, which decreases the chance of hands or clothes getting burned. Here are some other safety tips about fireworks to help get the best out of the holiday the safe way, courtesy of Safe Kids Worldwide:

  •  If you plan to use fireworks, make sure they are legal in your area.
  •  Do not wear loose clothing while using fireworks.
  •  Never light fireworks indoors or near dry grass.
  •  Point fireworks away from homes, and keep away from brush, leaves and flammable substances
  •  Stand several feet away from lit fireworks. If a device does not go off, do not stand over it to  investigate it. Put it out with water and dispose of it.
  •  Always have a bucket of water and/or a fire extinguisher nearby. Know how to operate the fire  extinguisher properly.
  • If a person is injured by fireworks, immediately go to a doctor or hospital. If an eye injury occurs, don’t allow the person to touch or rub it, as this may cause even more damage.

Being aware of the local firework laws are especially important. The Baltimore City Fire Department confirms that all fireworks, even sparklers are against the law in Baltimore City unless a permit and approval is given from the office of the Fire Marshall. Depending on the area, it is important to know the firework laws before having a display of your own. Violators of these laws are subject to a misdemeanor fine of up to $250. The holidays are about spending time with friends and family, so before deciding to make your own firework display, consider the consequences and alternatives for a safe and fun 4th of July.

For a PDF with more statistics on Firework Injuries from the US Consumer Product Safety Commission click here.

Sources:

http://www.baltimorecountymd.gov/Agencies/fire/safety%20education/fireworks.html
http://www.fireworkssafety.org/
https://www.safekids.org/tip/fireworks-safety-tips
http://www.cpsc.gov/en/Safety-Education/Neighborhood-Safety-Network/Posters/Fireworks-Injuries/

Taking Treatment & a Half Marathon, Together, One Step at A Time

The relationship between a cancer patient and their care provider is a special one.  Between radiation therapy appointments, hours of chemotherapy, and even sometimes surgery and recovery, there’s not much that can strengthen this bond, besides running a half marathon.

Dana and Tiffani

But Tiffani Tyer, a nurse practitioner in Radiation Oncology at the University of Maryland Greenebaum Comprehensive Cancer Center (UMGCCC), and Dana Deighton’s journey started long before this year’s Maryland Half Marathon & 5K.

About 3 years ago Dana was diagnosed with stage IV esophageal cancer.  At 43 years old with 3 young children, it was, in Dana’s words, “unfathomable.” She traveled up and down the East Coast looking for a treatment plan that would give her the most hope. Many acted like she was naïve and unrealistic for even seeking out treatments beyond palliative chemotherapy.

After much deliberation, Dana settled on a plan of 8 cycles of chemotherapy at one local hospital. During this treatment, a friend introduced Dana to Mohan Suntha, MD, a radiation oncologist at UMGCCC.

Within an hour of getting Dana’s information, Dr. Suntha gave her a call. While he agreed the appropriate preliminary step was chemotherapy, he did not close the door on her like many others.  Dr. Suntha and Dana continued to check in with each other throughout her chemotherapy treatments to see how things were going.

In December 2013, after Dana finished chemotherapy, she learned she would not be considered for radiation or surgery by the hospital where she was initially treated. She was told that the data did not support it. She was devastated. Dana returned to UMGCCC, where Dr. Suntha and Tiffani were always willing to reassess her situation and provide guidance when obstacles seemed insurmountable.  Knowing that every case is different, he agreed to reevaluate her.

tiffani dana and dr sunthaAfter careful consideration and determining that her distant disease had indeed resolved, he offered her local treatment with chemotherapy and radiation targeting the primary site in her esophagus.  While the local treatment helped, the primary site still showed evidence of persistent disease at the end of her treatment.  To try to avoid major thoracic surgery, an endoscopic mucosal resection was attempted, but was unfortunately unsuccessful. Dana was again devastated. She felt like it was just another blow to her journey to health and she was running out of options.

Dr. Suntha and Tiffani encouraged Dana to stay hopeful. They agreed along with many other providers that indeed she was in a difficult position. After many tumor board discussions and repeat imaging studies to confirm her extent of local disease thoracic surgeon Whitney Burrows, MD, was consulted. He discussed surgical salvage to address her only site of cancer.  Albeit risky, with no guarantee of a survival benefit, it was her only remaining local treatment option.  Recognized as a long shot with a real possibility of acute complications related to such a long and complicated surgery, she willingly consented to undergo the esophagectomy. From Dana’s view the benefit far outweighed the risk. She believed in her team and her surgeon, whose expertise is well established in post chemoradiation patients. It proved to be a good choice and offered a huge reward.  Dana recovered well and was cancer free and feeling great–until July 2015.

It was then that a routine interval scan revealed a new lymph node mass in her Axilla (near the armpit) was biopsied and confirmed to be recurrent esophageal cancer.  Dana had resigned herself to more draining rounds of chemotherapy after another surgery could not remove all of the cancer.  But again, Dr. Suntha, Tiffani, and medical oncologist, Dan Zandberg, MD, always made sure all options were presented and considered.

tiffani zandberg and sunthaDana’s case was represented to  their colleagues at a tumor board meeting on the Friday before she was supposed to start chemotherapy.  Drs. Suntha and  Zandberg called her that evening to  recommend  immunotherapy, which harnesses the power of a  patient’s immune system to fight cancer.  After a sleepless night, Dana agreed.   She now receives treatments of Nivolumab every 2 weeks for at least a year.

Dr. Suntha has always recognized that there’s something unusual about Dana’s case, and has often asked, “Is there something different about her biology? We don’t know.”

Dr. Suntha, he also believes that Dana’s strong will and clear ability to advocate for herself has facilitated part of the success of her care.

dana and tiffaniThroughout these three years, Dana describes herself as lucky enough to continue her usual regimen of walking, running, and exercising consistently.  She donated money to the Maryland Half Marathon & 5K to fund cancer research in the past, but feeling much healthier and up to a new challenge, she promised to run it in 2016. She has always ran 10 milers in her hometown of Alexandria, Virginia, but knew those 3 extra miles of hills in the Half Marathon would be challenging.
Despite her reservations, in a partnership with Tiffani, the Radiation Oncology Greene Street Dream Team was born. On May 14th, Tiffani and Dana ran the entire race together (even though, according to Dana, Tiffani could’ve run circles around her).  To date, they’ve raised more than $10,000. They’ve taken every step together in cancer treatment and every step in the half marathon & 5K – a true bond that will continue.

Fundraising for the Maryland Half Marathon and 5K that supports this Radiation Oncology Dream Team and their patients continues until June 30th.

You can donate to Tiffani & Dana’s team here.

UM Children’s Hospital Patient Gives Back in a Big Way

Michelle Kaminaris, a kindergarten teacher at Hampstead Hill Academy in East Baltimore, has seen kids miss school for all kinds of reasons. Like most of us, she never expected her own child to miss school due to a serious illness. But when her daughter Eva (an eighth grader at Hampstead Hill Academy) started showing flu-like symptoms, a trip to the doctor confirmed that Eva would be missing school due to pneumonia.

From there, Eva had more tests and doctors found a tumor on her ovaries. The tumor was removed after an emergency surgery, but she still had to spend time recovering at the University of Maryland Children’s Hospital (UMCH). While she endured a slew of poking and prodding and scary medical diagnoses, it was the Child Life team and other skilled nurses at UMCH who made her hospital stay a positive experience.

Group Photo

Eva (fourth from left) and Hampstead Hill Academy’s Kiwanis Builders Club pose with their donation to UMCH

“We had unbelievably phenomenal care. I never had to leave my daughter,” Michelle said. “One of the nurses even gave up his lunch hour to take Eva to play and walk around.”

Post-discharge and feeling better, Eva was determined to give back to the place that took such great care of her. She started looking online for ways to help and found UMCH’s toy wish list.

She sought help from her school’s Kiwanis Builders Club, and recruited some of her friends and classmates to help. The club, seven members strong, started planning fundraisers, bake sales, art supply and Band-Aid drives, and a paint night.

Shannon Joslin Builders Club

Shannon Joslin, Child Life Manager, describes the Child Life Program to the Hampstead Hill Academy Kiwanis Builders Club

The students stayed after school one day to stretch the canvases for the paint night by hand and helped cook food for the event. Thirty-five families came out after school to support the club and raise money for the cause.

The club went shopping for items on the UMCH wish list with the money from the fundraisers. They picked out high-demand items like DVDs, video games, building block sets and card games, all which they personally delivered to the hospital.

As Eva heads to high school, she wants to ensure that this is not a one-time donation. Even if she can’t start the club at her new high school, she plans to keep in touch and continue giving back to UMCH. Michelle’s youngest child, inspired by Eva’s involvement and by UMCH’s great care, plans continue the family tradition and join the Hampstead Hill Builders Club next year.

Many thanks to the Hampstead Hill Academy’s Kiwanis Builders Club! Your continued support of the Children’s Hospital ensures we have the resources available to make every patient’s stay comfortable and fun.

Learn more about the Child Life Program and meet the team.

Interested in giving to the Children’s Hospital? Here’s how you can help.


 

Pediatric Residents at Univeristy of Maryland Reach Out and Read

A string of rainy days in Baltimore made Friday the perfect day to stay inside and read a good book. And thanks to the efforts of some hard-working Pediatric Residents at the University of Maryland School of Medicine, more than 200 students in Baltimore City had a new story to read!

Throughout the morning, the pediatricians-to-be visited several schools in the University of Maryland Children’s Hospital community, including James McHenry Elementary-Middle School and Franklin Square Elementary in West Baltimore. They spent time interacting with the students, with the hopes of promoting a healthy attitude toward development and literacy at a young age.

James McHenry students had a special visitor: Baltimore City Council President Jack Young handed out books and spent time reading to four classrooms of Pre-K and Kindergarten students.

The Maryland Book Bank and the Maryland Chapter of the American Academy of Pediatrics donated the 200 books that went home with students.

The day of reading was a part of a nationwide “ROAR: Reach Out and Read” effort, which is a non-profit that works to incorporate books and literacy into pediatric care.

Friday was also designated as a “Call to Action” Day by the American Academy of Pediatrics to F.A.C.E Poverty: promote Food Security, Access to Health Care, Community, and Education.

Ear, Nose & Throat Team Returns from Medical Mission after Cyclone Winston Rocks Fiji


A 12-person team of nurses, surgeons, residents and anesthesiologists from the University of Maryland Medical Center have returned from their medical mission in Fiji.   Team members performed 15 surgeries and saw 150 patients before Tropical Cyclone Winston rocked the islands.   Watch the video above to hear about the mission from the team themselves.

 

Decoding Patient Care

By: Hope Gamper, Editorial Intern

Our understanding of the genetic code kicked off in 1953 when scientists Watson and Crick documented evidence of the double helix structure of DNA. Fifty years later the Human Genome Project, an initiative to map the entire human genome, was completed. Today, we know more about our As, Ts, Gs and Cs than ever before. This National DNA Day, April 25th**, let’s take a look at the ways knowing about genomics is beneficial to health care.

DNA is made up of billions of nucleotide pairs (those As, Ts, Gs and Cs) that are joined by hydrogen bonds. These bonds are very strong, and act as a reliable way to store our genetic information. Your complete set of genetic information is called your genome, which codes for everything from your hair color to how well you do in school, and it is part of what makes you you.

Your genome can also help doctors develop personalized treatment plans.

Patients with coronary artery disease at the University of Maryland Medical Center can receive long-term therapy based on their genetic information. Patients may elect to be tested for abnormal copies of the CYP2C19 gene, which can impact the efficacy of clopidogrel, an anticoagulant. Incorrect doses of drugs like clopidogrel can lead to serious heart attacks and strokes, so knowing a patient’s reaction before prescription is vital.

Advances in DNA sequencing and testing have opened the door for the more commonplace practice of genomic medicine. Every baby born in the United States is screened for inherited genetic diseases at birth, and whole genome sequencing can prevent misdiagnosis of an array of diseases from cerebral palsy to cystic fibrosis.

Applying new findings in genomic medicine on a routine clinical scale is a long and continuous process, but knowing more about the way the human genome works can only mean a bright future for personalized medicine.

DNAday

**Sponsored by the National Human Genome Research Institute (NHGRI), DNA Day is a celebration of genetics and genomics. For an online education kit, visit the NHGRI website: http://www.genome.gov/

Public Health Leaders Urge Vaccination Against Measles

Physician-in-Chief, University of Maryland Children’s Hospital

It is impossible today to turn on the TV or read the news without hearing about the current debate surrounding childhood vaccinations and the measles outbreaks in the United States.

As chair of the Department of Pediatrics at the University of Maryland School of Medicine, I took the opportunity to encourage parents to get their children vaccinated by participating in a joint statement with other pediatric and public health leaders from around Baltimore. Please consider the public health benefits of vaccinating your children, and talk to your pediatrician to get the answers you need to feel comfortable with this lifesaving decision.

Mac-and-Cheese Makeover

By Anne Haddad

Publications Editor

The cafeteria at the Medical Center has always made a mac-and-cheese to rival any home-baked version. The trouble was, it was high in fat and sodium. A group of interns in Clinical Nutrition Services accepted the challenge to revamp it without disappointing the hundreds of people who look forward to this comfort food.

The interns conducted a taste test with staff and visitors – who liked the lighter version a lot. The secret ingredients are pumpkin puree and vegetable base, which add flavor without being obvious. I can enjoy it now without feeling like I’m on the fast-track to cardiac care.Mac.2.AC9A0275 I usually have it with a side of steamed cauliflower or broccoli, which makes for a 300-calorie lunch.

I tried duplicating it at home, after the hospital’s executive chef, Stephen Mack, whose recipe makes enough for 150 portions, divided it by 10 for me. (See recipe below.) The whole family loved it, and even my super-taster daughter did not detect the pumpkin. The leftovers reheated well  in the microwave or in the oven.

The new version’s 13 grams total fat (7 grams of which is saturated fat), 65 mg cholesterol, and 388 mg sodium per portion fall well under the USDA maximum daily recommendations of 67 grams total fat, 16 grams saturated fat, 300 mg cholesterol, and 2300 mg sodium, based on a 2,000 calories-per-day diet.

University of Maryland Medical Center Macaroni and Cheese

Makes 15 4-ounce portions, 250 calories each

  • 1 pound of elbow macaroni
  • 3 whole eggs, lightly beaten
  • 1 TBS vegetable base (such as Better Than Bouillon or Trader Joe’s concentrated vegetable broth)
  • 2 TBS pureed canned pumpkin
  • 3.2 fluid ounces heavy whipping cream
  • 3.2 cups whole milk
  • 20 ounces (by weight, not volume) of shredded blend of cheddar and Monterey jack
  • 1 cup of panko bread crumbs

Boil and drain the macaroni and preheat the oven to 350 degrees.

After macaroni has cooled, stir in the vegetable base and pumpkin, then the  eggs.

Add half the cheese, reserving the other half for topping, and then the milk and cream. Stir the whole mixture gently but  thoroughly.

Coat a 9” by 13” baking pan with nonstick cooking spray and spread the macaroni mixture evenly in the pan. Sprinkle on the remaining cheese and the bread crumbs.

(If you like, cover and allow to refrigerate overnight.)

Bake uncovered for about 35 minutes, or 45 minutes if refrigerated overnight. Serve immediately.