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Posted on 13th June 2020 by Laura Magson

Welcome to Boyes Turner's Mesothelioma and Lung Cancer Webinar Series, this is the fifth in the series, a talk from Samantha Westbrook, Peritoneal Mesothelioma Clinical Nurse Specialist. Samantha talks to Laura Magson about peritoneal mesothelioma, what is happening now and what the future holds.

For more information about Mesothelioma UK visit their website: https://www.mesothelioma.uk.com/

Mesothelioma and Lung Cancer Webinar Series: Peritoneal Mesothelioma

Mesothelioma and Lung Cancer Webinar Series: Peritoneal Mesothelioma

Key points of this webinar

  • Overview of peritoneal mesothelioma
  • What is happening now
  • What the future holds

Laura’s accreditations

"It has been a long battle but we got there in the end"
I would like to take this opportunity to say a big thank you to you and your team for all your hard work, passion, dedication and professionalism which resulted in my successful claim.It has been a long battle but we got there in the end. Whatever happens in the future I now have the financial security that I deserve for myself and my family. I can now focus on my health and happiness.
"Absolutely fantastic "
The way you have worked with us has been absolutely fantastic and I don't feel we could have asked for more. The personal contact we have had with you has helped us cope with this difficult situation to the extent that everything has gone as smoothly as it could”.Laura’s efficiency, tenacity, kindness and empathy made this experience really stress free for us, for which we will be eternally grateful.

Transcript of this webinar

 

I'm Laura Magson,  I'm a solicitor at Boyes Turner and would like to welcome you all and many thanks for listening in today

I'm joined by Samantha Westbrook when we started organizing our annual study day last year I approached a number of speakers including Samantha who kindly agreed to talk about eight months ago now at our mesothelioma and lung cancer study day. I don't think anybody expected that that study day wouldn't be able to go ahead face to face in our offices as planned but nevertheless we've we've had to adapt. Samantha has kindly agreed to do a short webinar instead.

For those that don't know Samantha Westbrook is a peritoneal clinical nurse specialist at the peritoneal malignancy Institute at Basingstoke Hospital, her post has been funded by Mesothelioma UK since I think September 2018, it's a charity that's fantastic, it's nationwide and dedicated to Mesothelioma patients thank you Sam for carrying on in these unprecedented times I'll hand over to you now Samantha if you'd like to tell everybody what you're going to talk about today?

Oh hi good morning, hi Laura thank you for the kind introduction so in this one I'm going to talk to you about peritoneal mesothelioma I'm going to give you a little bit of an overview of peritoneal mesothelioma. We're going to look at the current landscape and what that looks like in the UK for the patients with peritoneal mesothelioma and then I'm going to touch on what what the future might hold and looking ahead a little bit more so I'm going to share my presentation with you.

So these are the numbers that have been recently published by the mesothelioma audit if we look at the statistics here there are about just over 7,000 patients in the UK diagnosed with mesothelioma in the two-year period this is 2016 2 18 of those about 260 cases are peritoneal mesothelioma and we can see here that the mean median age is around 71 there are more males and females but there are slightly more females than the males within the patient cases, this audit really showed the great work that's being done by the charities by the other hospitals with the National MDT's and all the regional NZ teas and in particular for us it showed that there was a doubling

of referrals to our national parents

know mesothelioma NDT from the previous

two years so that's a great achievement

for patients who are seeking that expert

advice and let's have a look at what

peritoneal mesothelioma is it's the

lining of the abdomen is the peritoneum

and what happens is the perineum

thickens when mesothelioma is present

and during that thickening it causes

fluid to collect now this fluid is

called ascites and when that happens the

abdomen swells the patient can be quite

uncomfortable with all that fluid there

there are two linings

there's the lining that's the visceral

lining which is next to the abdominal

organs and as the prize for lining that

lines the abdominal wall now personal

mesothelioma spreads outwards and around

it doesn't spread within it doesn't

infiltrate and it isn't him illogical

spread either it's quite unusual to see

the lymph glands affected by it and to

see any metastases out of the abdominal cavity it's very rare and it's very

uncommon at the moment we don't know of

any cure and and there are some thoughts

on how music a glioma guess for the

peritoneum and one thought is that be

crystals are ingested and slowly over

time they migrate from the lumen of the

GI tract to the peritoneum and the

latency period is slightly shorter than

that of the pleural mesothelioma

and that's been documented about around

20 years there are some documented cases

as long as Vestas causes of peritoneal mesothelioma

some say that radiation causes it so

that's the directly irradiated tissues

there's issue instances of recurrence

peritonitis and so patients who have

relapsing diverticulitis or patients with crohn's disease genetic dispositions and also and a virus called simian virus for T so if we look at peritoneal mesothelioma it's it's actually classified into some different subtypes we can put a couple into the low-grade spectrum and we can put some into what we call the higher grades and malignant spectrum in the low-grade we see

something called multi system is the video map and well-differentiatedPapillion is Aloma and in the high-grade malignant spectrum we see epithelioid and also chromatids and our biphasic and a distribution and the sites of disease can vary between each patient so the multi cystic is an a low-grade borderline malignant tumor it rarely spreads outside the afternoon and it does have high rates of recurrence

locally at the well differentiated papillary is even rarer we don't see

many of those patients with with this

and it's slightly more frequent in the

personally in the plural

our most common is the epithelial age

and slightly more rare is the Stockholm

it's weight and the biphasic the

patients often have a delayed diagnosis

and this is due to his symptoms being fairly nonspecific symptoms rather

common symptoms and that you could put

down to perhaps more and

more common issues so we have things

like Domino paintings we have abdominal swellings change in bowel habits Teagan weight

loss perhaps the patient has had a hernia and loss of appetite so quite sort of nonspecific some red flags there

for cancer symptoms and patients often go down different diagnostic pathways

and before they get to this diagnosis and sadly the patients do present at a an advanced tumor stage so how do we

diagnose it well often patients would have had a CT scan and for us when we're looking at CT scan is extremely important to look at the small bowel using this CT and we want to an almost estimate the degree of disease on the small bowel and and and that can tell us what and surgical options are available pet and CT scans yet show us superiority

over the CT scans diagnostic laparoscopy

is are something that we use to look at

08:05

the disease distribution and estimate

08:08

the volume of disease and take biopsies

08:12

you can aspirate the ascites so that

08:15

fluid in the abdominal cavity we were

08:17

talking about earlier and that that that

08:19

can be helpful and but often it's non

08:21

diagnostic to give us a diagnosis of

08:24

peritoneal mesothelioma there are

08:32

options of treatment pathways and some

08:36

patients go onto a surveillance program

08:37

where we watch the disease they have

08:41

scans they will interview interval scans

08:44

over a period of time just watching the

08:47

disease some patients opt to have a

08:50

chemotherapy and and some perhaps would

08:53

consider having a surgery there are

08:56

clinical trial options available as well

08:59

and for patients who perhaps not

09:02

suitable for surgery or have had a

09:03

couple of

09:04

lines of chemotherapies so we just have

09:10

a quick look at the history NHS England

09:15

in 2015

09:17

made the decision not to routinely

09:19

commissioned surgery for peritoneal

09:22

mesothelioma the surgery that we do at

09:24

Basingstoke is called cytoreductive

09:27

surgery and hyperthermic chemotherapy we

09:33

shorten that Cirrus and HIPEC because

09:35

it's a bit of a mouthful to say all the

09:37

time and they the standard treatment is

09:41

is the chemotherapy now we have we have

09:47

a special interest in personal

09:49

mesothelioma amazing stick and music UK

09:52

in particular as well and in March 2016

09:57

the team decided to set up a national

10:00

personally glioma mzt meeting and

10:03

essentially they wanted to look at and

10:06

gain a consensus on what treatment

10:10

advice they can give and to look at

10:12

trends and how patients do over time

10:16

collecting their evidence and looking at

10:19

the data and the decision was made to

10:22

continue offering the surgery for

10:25

personal mesothelioma at our Hospital so

10:31

the MDT looks a bit like this it's a is

10:34

this a virtual MDT bit like what we're

10:37

all used to at the moment we have the

10:40

peritoneal malignancy surgeons at Good

10:43

Hope in Birmingham dial in and the

10:47

matter in Dublin dial in as well we have

10:51

expert pathologist who is well known in

10:56

in looking at personally see glioma we

10:59

have specialist nurse we have our

11:01

radiologist we have an oncologist and

11:03

our NDT coordinator collects all the

11:05

information for the meeting and we

11:08

review all the histology so we ask for

11:10

all the tissue blocks than the biopsies

11:14

to be sent to us for our pathologist her

11:17

have a look and to give a second opinion

11:19

all the images are reviewed we look at

11:22

the clinical information we might have

11:25

DVDs of laparoscopy that have been done

11:28

in the local hospitals or pictures for

11:30

us to look at I myself may have spoken

11:34

to the patient specialist nurse in their

11:37

local hospital or I might have actually

11:39

spoken to the patients or the families

11:40

themselves acting on their behalf and

11:42

knowing their wishes we recommend a

11:46

treatment pathway and that may be seeing

11:49

on an oncologist or it may be looking at

11:52

other any clinical trials available or

11:55

it may be looking at assessing them for

11:57

the suitability for the surgery it just

12:03

popped in a table here we recently

12:05

published a paper of our MD T and it is

12:09

it's interesting to have a look at the

12:11

number of cases that we looked at the

12:14

majority as we know the most common

12:16

epithelioid news Vienna followed by the

12:19

multi cystic and in the biphasic s--

12:22

after that and what we found from the

12:25

data was that patients who received the

12:29

Cirrus and HIPEC surgery showed a better

12:32

of one two and three year overall

12:34

survival and those were in patients that

12:37

were carefully selected through this MDT

12:39

process so what does the e surgery

12:44

involve well completely removing on this

12:47

tumor we call a complete site reduction

12:49

and its aims to remove all of that

12:51

macroscopic tumor but it can come with

12:55

its complications such as hemorrhages or

12:58

fish to lose perforations the wounds not

13:01

healing or abscesses and and at times we

13:05

can offer operations to remove a bulk of

13:09

disease perhaps if that's causing

13:11

problems for a patient discomfort pain

13:13

so we can help to remove disease that's

13:16

and causing symptoms there so in the

13:22

sugar bay

13:22

technique this is all the procedures

13:24

that are involved now not every patient

13:26

will have all of these procedures it's

13:29

specific to where their diseases so

13:32

right sides that the bowel can be

13:34

removed we would remove something called

13:37

the Ament 'm which is a fat apron but

13:39

over lays over the top of all of the

13:42

abdominal organs and we spleen may be

13:46

removed the gallbladder may be removed

13:49

patients may need a hysterectomy or

13:52

their ovaries removed we would strip the

13:56

peritoneum and strip the linings of the

13:58

diaphragm and perhaps the surface of the

14:03

liver and in some cases and there are

14:05

areas down in the rectum that needs to

14:07

be resected now the HIPEC is the heated

14:13

chemotherapy liquid and so this

14:16

addresses all the disease that we

14:17

perhaps can't see the macroscopic

14:19

disease we've removed all of the disease

14:21

that we can see with the crs and then

14:25

we're addressing the macroscopic disease

14:27

which is the chemotherapy wash now this

14:31

is isolated to the personal cavity it's

14:34

it's pumped in I'll show you the machine

14:37

on the next slide and it's left in the

14:40

cavity for about 60 minutes heated and

14:43

the organs are bathed and there's no

14:46

toxicity or side effects to the patient

14:49

and possible tiredness or nausea but you

14:54

would expect that after operation anyway

14:57

so this is what it looks like it's a

15:01

metal scaffolding there's built around

15:05

and then the tubes by the machine

15:08

pumping the hot chemotherapy wash in the

15:11

organs are bathed and then it's removed

15:16

for a patient who's undergoing this

15:19

surgery and this is sort of what their

15:22

initial journey might might look like on

15:26

the day of admission they'll come to us

15:28

two days before the actual operation

15:31

itself and all the usual paperwork's are

15:35

completed

15:36

now give them a liquid for a bell and to

15:39

clear out the boughs little pickle

15:41

accent she's a bowel prep and they will

15:44

be having clear fluids only and the day

15:49

before the operation is one of the

15:50

busier days actually so miss blue team

15:53

will come and see the patient and talk

15:56

to them we have dedicated stoma team who

16:00

come and see the patient so that's the

16:03

patient's who perhaps are having part of

16:05

their bowel removed and need to have a

16:07

bag on the outside on their tummy for

16:10

the stool to come out of that could be

16:12

either permanent or temporary the

16:16

anesthetist so the person who's putting

16:18

the patient to sleep and giving all the

16:20

sedation will come and see them we have

16:23

team of dieticians they will talk about

16:26

the artificial feeding that they'll be

16:30

getting for the first ten days and then

16:32

how they reintroduce food we have

16:35

physiotherapists and exercise

16:37

specialists and they will see the

16:39

patient really from the beginning and

16:41

out of the surgery and to get them up

16:44

and moving we offer them a visit to the

16:47

intensive care unit where they will stay

16:50

the first 24 hours minimum are to their

16:53

operation and the nurse myself I'll I'll

16:57

see the patient as well and we we talk

16:59

through all the ins and outs and what

17:00

what it might look like after the

17:02

operation and all those drains and the

17:04

drips that they that they will have and

17:07

on the day of the operation so they

17:09

don't have anything else to eat and

17:11

drink from midnight the night before and

17:13

they get woken up about 6 o'clock and

17:16

start getting getting ready a relative's

17:19

welcome to come and take them to the

17:21

operating theatre and the relatives will

17:25

receive two phone calls from the surgeon

17:27

during the day one usually just after

17:30

lunch and then one at the end these

17:34

patients do have complex care needs

17:36

after this operation often they would

17:39

have chest rings if they've had those

17:41

diaphragms stripped as I had mentioned

17:43

earlier they have multiple abdominal

17:46

drains to drain out any fluid

17:48

collections

17:50

they'd have to learn about this straight

17:51

macare if indeed they have a steamer all

17:54

patients do pain relief is one of our

17:57

big focuses so we really didn't want the

17:59

patients be any in any pain they'll have

18:02

an epidural in place and a button that

18:06

they can press to deliver extra

18:08

painkillers if they need it they are

18:12

ultimately artificially fed for around

18:14

ten days and like I said we we get the

18:18

patients up and moving very early on

18:21

sometimes patients will have the

18:23

chemotherapy wash after the operation as

18:27

well and that's what we shortened to

18:29

something called epic it's not always

18:32

done but it can be inserted through one

18:35

of those drains and left in under 24

18:38

hours and drained out the next day

18:41

now for a lot of patients this is an

18:45

emotional time and we recognize that and

18:48

so we do offer psychological support we

18:52

have a psychologist team for our

18:56

patients and they're screened before for

18:59

any anxiety and depression so that we're

19:02

able to support them the best we can

19:04

during this process and there are

19:07

various ways for us to get to know our

19:10

patients and this is something called

19:12

feeling out of Wankel this is me and we

19:15

can learn a little bit more about the

19:16

patient before they come and stay with

19:18

us and we offer inpatient Diaries as

19:21

well so there are a lot of worries and

19:27

concerns for these patients and I think

19:32

at the top of the list but for many and

19:34

which is an unsurprising is the

19:38

prognosis and what does this mean and

19:40

can we remove all of their tumor have we

19:44

got it all out how much longer will they

19:47

live for and so we have to support those

19:50

patients and try and answer those

19:52

questions as best we can the stoma can

19:55

be something that nobody particularly

19:58

wants and so we offer some counselling

20:00

for that the scar isn't

20:03

and see from the picture is a is a big

20:05

scar and for a lot of people that's

20:07

quite unsightly and it can take some

20:10

time to look at their belly button gets

20:12

removed during that process as well

20:13

which is quite unusual too when you look

20:16

down and see there's no belly button

20:19

so the scar can be a focus for a lot of

20:22

patients they're with us for about three

20:24

weeks and then afterwards when they go

20:27

home we offer a follow-up care so we do

20:31

telephone calls at certain points to

20:34

check that the patients are recovering

20:36

well at home and eleazar their local

20:39

teams so my role probably this bliss

20:46

isn't isn't exhaustive I support the

20:50

patients often remotely not only those

20:53

that are having this surgery but those

20:56

are going through all different

20:59

treatments in the UK I would signpost

21:03

them to various teams or various

21:07

services help them with any symptoms

21:12

that they are struggling with seeing if

21:14

there are all ways that we can help to

21:16

manage those speaking with their

21:18

specialist teams and their local

21:20

hospitals and specialist nurses and

21:26

often it can be talking about the

21:27

disease itself as we said that it's a

21:31

very rare disease and they find that

21:36

they want to talk to the people who have

21:39

experiencing in this service development

21:44

so we look at how we can improve our

21:47

treatments that were offering how can we

21:51

get it known what we're doing amazing

21:54

stake so I just thought I'd run through

21:59

a quick case study with you here just to

22:01

sort of set a bit more of a picture of

22:04

them perhaps what it might look like for

22:07

a patient

22:09

this referral came in last summer a

22:12

young female and with fit and well and

22:15

no medical history and she had they used

22:18

nonspecific symptoms that we spoke about

22:21

and was bit to handle something called

22:25

irritable bowel syndrome but these

22:28

didn't resolve and so she was referred

22:32

into the hospital and she had a

22:35

laparoscopy though this was her and

22:37

something to explore what might be going

22:40

on and inside the pelvic area looked

22:43

abnormal and so there was a biopsy that

22:45

was taken and this unfortunately came

22:49

back inconclusive and so no diagnosis

22:53

could be given so she went through a

22:55

second biopsy and that was reported as

22:59

the well differentiated papillary Parana

23:03

mesothelioma and that was the one that

23:06

we spoke about us it's in the low-grade

23:09

spectrum and she was informed by her

23:12

local team that this was something that

23:14

was low-grade and indolent and was

23:20

informed that her treatment options

23:22

could could bury and it could be either

23:24

the watch and wait or pass there might

23:26

be some chemotherapy or or an operation

23:28

might be needed so her local team

23:31

referred us referred her to us at our

23:34

national MDT and we had a look at that

23:36

in August and our pathologists had a

23:39

look and subtype t as epithelioid say

23:43

that moved it over into the malignant

23:46

spectrum and we do a particular test

23:52

calling ki-67 which is is slightly a

23:55

prognostic indicator and hers was around

23:58

20% around 9% is is that normal see

24:03

moving up higher is likely more

24:05

aggressive we had a look at her scans

24:09

which sewed quite extensive disease in

24:12

the in the lower part of in the pelvis

24:14

and their personal linings and also on

24:17

the diaphragm linings and we we

24:22

suggested that she'd

24:23

should consider some fertility options

24:27

and we had a look at the DVD from the

24:30

laparoscopy that was done in her local

24:33

Astra and it was quite difficult for us

24:34

to have a look on us to see the small

24:36

bowel and see if there was any disease

24:37

there so we decided we'd offer her our

24:42

patients appointment and we would do a

24:44

laparoscopy here at phasing snake and to

24:47

assess the disease so we did that in

24:50

October and it was decided that her

24:54

disease was operable and we'd be able to

24:56

achieve that full sight reduction and

25:00

that no bowel resections would be needed

25:02

and she'd in the meantime seen her

25:06

fertility team and her successful egg

25:09

collection so in November she had her

25:14

operation she had the CRS and HIPEC

25:17

treatment as you can see there there was

25:20

disease in quite a lot of areas we

25:25

removed peritoneal linings on the left

25:28

and the right and the immense him which

25:30

was that fat apron we removed her spleen

25:33

and she had an okay suspect me

25:36

we removed the linings of both of her

25:39

diaphragms on the left and the right you

25:41

remove the linings in her pelvis she had

25:45

a total hysterectomy a removal of her

25:49

ovaries and we did a remove her appendix

25:55

and she had a bladder repair as well and

25:59

there was a slight tear there and then

26:01

she had the Hawking therapy wash for an

26:04

hour afterwards and she had when she

26:07

came out the operation she had full

26:09

abdominal drains the right chest drain

26:12

another drain she was in the operation

26:15

room for about seven and a half hours

26:17

and with a minimal blood loss she

26:21

recovered really well after the

26:23

operation and after three weeks she was

26:25

discharged to her local team for

26:28

monitoring regularly and we recommend

26:31

Daniel scans so that was a really good

26:35

outcome for that patient

26:37

and referred to the National MDT where

26:40

we looked and she was suitable for the

26:43

full surgery and her outcome was with

26:47

successful after the operation simply

26:53

have a look into the future and what's

26:55

what's ahead of us well we we want to

26:58

continue our MD T and we will continue

27:01

that developing it looking at the

27:04

patients that have been referred over

27:06

the time and how they are doing what

27:09

treatments they received to get an idea

27:12

on on how these patients are being

27:14

treated and which ones are being treated

27:16

in which part of that spectrum in the

27:19

lower grade and the high grade we aim to

27:23

go back to NHS England with our data and

27:27

data that's been published worldwide

27:28

about the CRS and HIPEC surgery and ask

27:33

for them to Commission the surgery we're

27:36

looking at offering a prehabilitation

27:39

service for the surgical patients so

27:42

helping them to get fit and being best

27:47

shape as possible for recovery

27:50

afterwards we are looking at the

27:53

clinical trials that are available with

27:56

the systemic treatments that that can be

27:59

given for these patients and

28:00

immunotherapy is something that's at the

28:03

forefront at the moment we are looking

28:06

at something called PI Peck which is the

28:09

which is a pressurized chemotherapy

28:12

that's done at laparoscopy and that's

28:15

always a little sprayed into the

28:16

abdominal cavity and that's something

28:18

that we're looking at at the moment and

28:20

I'm watching the data worldwide and

28:23

thinking about whether we can offer

28:25

something in a clinical trial setting we

28:30

need to develop more information for

28:32

patients and leaflets and online

28:35

information and I think one of the big

28:39

things that these these patients and

28:41

their families that are asking for is is

28:43

support for one another and we are

28:47

looking at ways at doing virtual support

28:49

groups

28:50

and an events that we can do and to help

28:53

them talk to each other and share their

28:56

stories so in summary we have a look at

29:02

what we've just spoken about Paris

29:03

anomalies the MU is extremely rare and

29:06

it has links with us best exposure and

29:10

the chemotherapy is a good treatment

29:12

option which does gives limited benefits

29:15

is the palliative treatment and from

29:18

what we've seen the work that we're

29:20

doing we can achieve some good surgical

29:23

outcomes

29:24

for those patients that have been

29:26

carefully selected by the MDT thank you

29:32

a really helpful insight into personal

29:36

mesothelioma I think what you said about

29:39

just providing the support it's all the

29:43

patients but also pre and post operation

29:45

I think that will be really reassuring

29:47

some of the patients listening to your

29:51

presentation and it's also just kind of

29:55

dawned on me about the the remotes MDT's

29:58

that you you and the team have because

30:01

obviously I'm assuming those nd T's go

30:03

ahead because of geography or have done

30:05

in the past because you've got

30:06

specialists from all over the country

30:08

you've got treating patients not

30:12

necessarily in your local area and I

30:15

think we've shown haven't we that those

30:17

support group meetings as well can go

30:19

ahead remotely so I think that's you

30:21

know it's a really positive step that

30:23

you know you can hopefully start to

30:25

offer that remote support group as well

30:27

yes absolutely so I think we're going to

30:31

start our first virtual support group on

30:34

the 3rd of July which is the action miss

30:37

video today this is being done virtually

30:40

and hosted by the UK news Alliance and

30:44

I'm going to run a similar and seem cool

30:48

in the morning and for patients or their

30:51

families if they want to dial in and we

30:54

can have a chance with other people

30:57

around the UK and then that will launch

30:59

into the events that's being held by the

31:03

Alliance

31:04

breanne so I've got one question just

31:08

about the statistics that you mentioned

31:10

that the right at the beginning and of

31:12

course we see more males with

31:14

mesothelioma but what I was particularly

31:16

interested in really is with the females

31:19

the instance the peritoneal mesothelioma

31:21

is that little bit higher than for

31:23

plural and is there any reason behind

31:26

that do we know I think we could

31:29

probably have a look at those non

31:32

asbestos causes in a bit more detail and

31:36

perhaps those will mean that patients

31:41

with female patients perhaps that are

31:43

predisposed more the lower grade gliomas

31:48

the the multi sistex they seem to be

31:53

more prevalent in females as well and

31:55

there could be some hormonal link there

32:00

okay and our final question is from one

32:04

of the attendees so it's quite a

32:08

specific question that you may not be

32:10

able to answer exactly but he is at

32:13

Basin State Hospital and he wants to

32:15

know really if his CT scan is due to go

32:20

ahead in August obviously we're in a bit

32:23

of uncharted territory at the moment

32:24

what's the feeling on whether or not a

32:27

CT scan is happening as normal will it

32:29

be the stones you know what what do you

32:31

think might happen yet those services

32:35

are still running there are some slight

32:37

delays but I think we're seeing

32:40

particularly today services in the

32:43

retail industry all up and running today

32:46

and I think you I think we'll see a

32:49

quick escalation of services resuming

32:53

they're not not to be too panics about

32:56

an August scan and just to reassure

32:59

patients that we will get through their

33:02

routine scans and as as quick as we can

33:06

great it's really helpful Thank You

33:09

Samantha and thank you for sharing your

33:11

your time with us and taking the time

33:13

out today

33:14

many banks thanks for having me

English (auto-generated)

I'm Laura Maxon I'm a solicitor please

00:18

Turner welcome to you all and many

00:20

thanks for listening in today I'm joined

00:22

by Samantha Westbrook when we started

00:25

organizing our annual study day last

00:28

year I approached a number of speakers

00:30

including Samantha who kindly agreed to

00:32

talk about eight months ago now as our

00:35

mesothelioma and lung cancer study day I

00:37

don't think anybody expected that that

00:40

study day wouldn't be able to go ahead

00:41

face to face in our offices as planned

00:44

but nevertheless we've we've had to

00:46

adapt samantha has kindly agreed to do a

00:49

short webinar instead for those that

00:53

don't know Samantha Westbrook is a

00:54

peritoneal clinical nurse specialist at

00:57

the peritoneal malignancy Institute at

00:59

Basingstoke Hospital her post has been

01:02

funded by music the UK since I think

01:06

September 2018 it's a charity that's

01:09

fantastic it's nationwide and dedicated

01:12

to these at the Yeomen patients thank

01:14

you Sam for carrying on in these

01:16

unprecedented times I'll hand over to

01:18

you now Samantha if you'd like to tell

01:20

everybody what you're going to talk

01:22

about today oh hi good morning hi Laura

01:26

thank you for the kind introduction so

01:29

this one I'm going to talk to you about

01:30

peritoneal mesothelioma I'm going to

01:33

give you a little bit of an overview of

01:35

the peritoneal mesothelioma we're going

01:38

to look at the current landscape for

01:42

what that looks like in the UK for the

01:44

patients with peritoneal mesothelioma

01:46

and then I'm going to touch on what what

01:49

the future might hold and looking ahead

01:51

a little bit more so I'm going to share

01:53

my presentation with you so these are

01:55

the numbers that have been recently

01:57

published by the mesothelioma audit if

02:01

we look at the statistics here there are

02:04

about just over 7,000 patients in the UK

02:07

diagnosed with mesothelioma in the

02:11

two-year period this is 2016 2 18 of

02:15

those about 260 cases are peritoneal

02:19

mesothelioma and we can see here that

02:22

the mean median age is around 71 there

02:26

are more males and

02:28

females but there are slightly more

02:30

females than the males within the

02:32

parents Neil cases this audit really

02:37

showed the great work that's being done

02:40

by the charities by the other hospitals

02:43

with the National MDT's and all the

02:46

regional NZ teas and in particular for

02:49

us it showed that there was a doubling

02:52

of referrals to our national parents

02:54

know mesothelioma NDT from the previous

02:58

two years so that's a great achievement

03:00

for patients who are seeking that expert

03:03

advice and let's have a look at what

03:06

peritoneal mesothelioma is it's the

03:12

lining of the abdomen is the peritoneum

03:14

and what happens is the perineum

03:18

thickens when mesothelioma is present

03:21

and during that thickening it causes

03:25

fluid to collect now this fluid is

03:27

called ascites and when that happens the

03:30

abdomen swells the patient can be quite

03:32

uncomfortable with all that fluid there

03:34

there are two linings

03:36

there's the lining that's the visceral

03:38

lining which is next to the abdominal

03:40

organs and as the prize for lining that

03:43

lines the abdominal wall now personal

03:46

mesothelioma spreads outwards and around

03:49

it doesn't spread within it doesn't

03:52

infiltrate and it isn't him illogical

03:55

spread either it's quite unusual to see

03:58

the lymph glands affected by it and to

04:02

see any metastases out of the abdominal

04:04

cavity it's very rare and it's very

04:09

uncommon at the moment we don't know of

04:12

any cure and and there are some thoughts

04:16

on how music a glioma guess for the

04:19

peritoneum and one thought is that be

04:25

crystals are ingested and slowly over

04:29

time they migrate from the lumen of the

04:31

GI tract to the peritoneum and the

04:35

latency period is slightly shorter than

04:36

that of the pleural mesothelioma

04:39

and that's been documented about around

04:40

20 years there are some documented cases

04:46

as long as Vestas causes of personal

04:49

mesothelioma

04:50

some say that radiation causes it so

04:55

that's the directly irradiated tissues

04:58

there's issue instances of recurrence

05:03

peritonitis and so patients who have

05:06

relapsing diverticulitis or patients

05:09

with crohn's disease genetic

05:12

dispositions and also and a virus called

05:16

simian virus for T so if we look at

05:21

personal mesothelioma it's it's actually

05:24

classified into some different subtypes

05:26

we can put a couple into the low-grade

05:29

spectrum and we can put some into what

05:32

we call the higher grades and malignant

05:34

spectrum in the low-grade we see

05:37

something called multi system is the

05:38

video map and well-differentiated

05:40

Papillion is Aloma and in the high-grade

05:44

malignant spectrum we see epithelioid

05:47

and also chromatids and our biphasic and

05:51

a distribution and the sites of disease

05:54

can vary between each patient so the

05:59

multi cystic is an a low-grade

06:01

borderline malignant tumor it rarely

06:04

spreads outside the afternoon and it

06:06

does have high rates of recurrence

06:10

locally at the well differentiated

06:13

papillary is even rarer we don't see

06:16

many of those patients with with this

06:18

and it's slightly more frequent in the

06:22

personally in the plural

06:24

our most common is the epithelial age

06:27

and slightly more rare is the Stockholm

06:33

it's weight and the biphasic the

06:38

patients often have a delayed diagnosis

06:41

and this is due to dis symptoms being

06:44

fairly nonspecific symptoms rather

06:46

common symptoms and that you could put

06:49

down to perhaps more and

06:51

more common issues so we have things

06:56

like Domino paintings we have abdominal

06:58

swellings

07:00

change in bowel habits Teagan weight

07:03

loss perhaps the patient has had a

07:06

hernia and loss of appetite so quite

07:09

sort of nonspecific some red flags there

07:12

for cancer symptoms and patients often

07:15

go down different diagnostic pathways

07:17

and before they get to this diagnosis

07:20

and sadly the patients do present at a

07:23

at an advanced tumor stage so how do we

07:28

diagnose it well often patients would

07:31

have had a CT scan and for us when we're

07:34

looking at CT scan is extremely

07:37

important to look at the small bowel

07:39

using this CT and we want to an almost

07:42

estimate the degree of disease on the

07:46

small bowel and and and that can tell us

07:49

what and surgical options are available

07:53

pet and CT scans yet show us superiority

07:57

over the CT scans diagnostic laparoscopy

08:01

is are something that we use to look at

08:05

the disease distribution and estimate

08:08

the volume of disease and take biopsies

08:12

you can aspirate the ascites so that

08:15

fluid in the abdominal cavity we were

08:17

talking about earlier and that that that

08:19

can be helpful and but often it's non

08:21

diagnostic to give us a diagnosis of

08:24

peritoneal mesothelioma there are

08:32

options of treatment pathways and some

08:36

patients go onto a surveillance program

08:37

where we watch the disease they have

08:41

scans they will interview interval scans

08:44

over a period of time just watching the

08:47

disease some patients opt to have a

08:50

chemotherapy and and some perhaps would

08:53

consider having a surgery there are

08:56

clinical trial options available as well

08:59

and for patients who perhaps not

09:02

suitable for surgery or have had a

09:03

couple of

09:04

lines of chemotherapies so we just have

09:10

a quick look at the history NHS England

09:15

in 2015

09:17

made the decision not to routinely

09:19

commissioned surgery for peritoneal

09:22

mesothelioma the surgery that we do at

09:24

Basingstoke is called cytoreductive

09:27

surgery and hyperthermic chemotherapy we

09:33

shorten that Cirrus and HIPEC because

09:35

it's a bit of a mouthful to say all the

09:37

time and they the standard treatment is

09:41

is the chemotherapy now we have we have

09:47

a special interest in personal

09:49

mesothelioma amazing stick and music UK

09:52

in particular as well and in March 2016

09:57

the team decided to set up a national

10:00

personally glioma mzt meeting and

10:03

essentially they wanted to look at and

10:06

gain a consensus on what treatment

10:10

advice they can give and to look at

10:12

trends and how patients do over time

10:16

collecting their evidence and looking at

10:19

the data and the decision was made to

10:22

continue offering the surgery for

10:25

personal mesothelioma at our Hospital so

10:31

the MDT looks a bit like this it's a is

10:34

this a virtual MDT bit like what we're

10:37

all used to at the moment we have the

10:40

peritoneal malignancy surgeons at Good

10:43

Hope in Birmingham dial in and the

10:47

matter in Dublin dial in as well we have

10:51

expert pathologist who is well known in

10:56

in looking at personally see glioma we

10:59

have specialist nurse we have our

11:01

radiologist we have an oncologist and

11:03

our NDT coordinator collects all the

11:05

information for the meeting and we

11:08

review all the histology so we ask for

11:10

all the tissue blocks than the biopsies

11:14

to be sent to us for our pathologist her

11:17

have a look and to give a second opinion

11:19

all the images are reviewed we look at

11:22

the clinical information we might have

11:25

DVDs of laparoscopy that have been done

11:28

in the local hospitals or pictures for

11:30

us to look at I myself may have spoken

11:34

to the patient specialist nurse in their

11:37

local hospital or I might have actually

11:39

spoken to the patients or the families

11:40

themselves acting on their behalf and

11:42

knowing their wishes we recommend a

11:46

treatment pathway and that may be seeing

11:49

on an oncologist or it may be looking at

11:52

other any clinical trials available or

11:55

it may be looking at assessing them for

11:57

the suitability for the surgery it just

12:03

popped in a table here we recently

12:05

published a paper of our MD T and it is

12:09

it's interesting to have a look at the

12:11

number of cases that we looked at the

12:14

majority as we know the most common

12:16

epithelioid news Vienna followed by the

12:19

multi cystic and in the biphasic s--

12:22

after that and what we found from the

12:25

data was that patients who received the

12:29

Cirrus and HIPEC surgery showed a better

12:32

of one two and three year overall

12:34

survival and those were in patients that

12:37

were carefully selected through this MDT

12:39

process so what does the e surgery

12:44

involve well completely removing on this

12:47

tumor we call a complete site reduction

12:49

and its aims to remove all of that

12:51

macroscopic tumor but it can come with

12:55

its complications such as hemorrhages or

12:58

fish to lose perforations the wounds not

13:01

healing or abscesses and and at times we

13:05

can offer operations to remove a bulk of

13:09

disease perhaps if that's causing

13:11

problems for a patient discomfort pain

13:13

so we can help to remove disease that's

13:16

and causing symptoms there so in the

13:22

sugar bay

13:22

technique this is all the procedures

13:24

that are involved now not every patient

13:26

will have all of these procedures it's

13:29

specific to where their diseases so

13:32

right sides that the bowel can be

13:34

removed we would remove something called

13:37

the Ament 'm which is a fat apron but

13:39

over lays over the top of all of the

13:42

abdominal organs and we spleen may be

13:46

removed the gallbladder may be removed

13:49

patients may need a hysterectomy or

13:52

their ovaries removed we would strip the

13:56

peritoneum and strip the linings of the

13:58

diaphragm and perhaps the surface of the

14:03

liver and in some cases and there are

14:05

areas down in the rectum that needs to

14:07

be resected now the HIPEC is the heated

14:13

chemotherapy liquid and so this

14:16

addresses all the disease that we

14:17

perhaps can't see the macroscopic

14:19

disease we've removed all of the disease

14:21

that we can see with the crs and then

14:25

we're addressing the macroscopic disease

14:27

which is the chemotherapy wash now this

14:31

is isolated to the personal cavity it's

14:34

it's pumped in I'll show you the machine

14:37

on the next slide and it's left in the

14:40

cavity for about 60 minutes heated and

14:43

the organs are bathed and there's no

14:46

toxicity or side effects to the patient

14:49

and possible tiredness or nausea but you

14:54

would expect that after operation anyway

14:57

so this is what it looks like it's a

15:01

metal scaffolding there's built around

15:05

and then the tubes by the machine

15:08

pumping the hot chemotherapy wash in the

15:11

organs are bathed and then it's removed

15:16

for a patient who's undergoing this

15:19

surgery and this is sort of what their

15:22

initial journey might might look like on

15:26

the day of admission they'll come to us

15:28

two days before the actual operation

15:31

itself and all the usual paperwork's are

15:35

completed

15:36

now give them a liquid for a bell and to

15:39

clear out the boughs little pickle

15:41

accent she's a bowel prep and they will

15:44

be having clear fluids only and the day

15:49

before the operation is one of the

15:50

busier days actually so miss blue team

15:53

will come and see the patient and talk

15:56

to them we have dedicated stoma team who

16:00

come and see the patient so that's the

16:03

patient's who perhaps are having part of

16:05

their bowel removed and need to have a

16:07

bag on the outside on their tummy for

16:10

the stool to come out of that could be

16:12

either permanent or temporary the

16:16

anesthetist so the person who's putting

16:18

the patient to sleep and giving all the

16:20

sedation will come and see them we have

16:23

team of dieticians they will talk about

16:26

the artificial feeding that they'll be

16:30

getting for the first ten days and then

16:32

how they reintroduce food we have

16:35

physiotherapists and exercise

16:37

specialists and they will see the

16:39

patient really from the beginning and

16:41

out of the surgery and to get them up

16:44

and moving we offer them a visit to the

16:47

intensive care unit where they will stay

16:50

the first 24 hours minimum are to their

16:53

operation and the nurse myself I'll I'll

16:57

see the patient as well and we we talk

16:59

through all the ins and outs and what

17:00

what it might look like after the

17:02

operation and all those drains and the

17:04

drips that they that they will have and

17:07

on the day of the operation so they

17:09

don't have anything else to eat and

17:11

drink from midnight the night before and

17:13

they get woken up about 6 o'clock and

17:16

start getting getting ready a relative's

17:19

welcome to come and take them to the

17:21

operating theatre and the relatives will

17:25

receive two phone calls from the surgeon

17:27

during the day one usually just after

17:30

lunch and then one at the end these

17:34

patients do have complex care needs

17:36

after this operation often they would

17:39

have chest rings if they've had those

17:41

diaphragms stripped as I had mentioned

17:43

earlier they have multiple abdominal

17:46

drains to drain out any fluid

17:48

collections

17:50

they'd have to learn about this straight

17:51

macare if indeed they have a steamer all

17:54

patients do pain relief is one of our

17:57

big focuses so we really didn't want the

17:59

patients be any in any pain they'll have

18:02

an epidural in place and a button that

18:06

they can press to deliver extra

18:08

painkillers if they need it they are

18:12

ultimately artificially fed for around

18:14

ten days and like I said we we get the

18:18

patients up and moving very early on

18:21

sometimes patients will have the

18:23

chemotherapy wash after the operation as

18:27

well and that's what we shortened to

18:29

something called epic it's not always

18:32

done but it can be inserted through one

18:35

of those drains and left in under 24

18:38

hours and drained out the next day

18:41

now for a lot of patients this is an

18:45

emotional time and we recognize that and

18:48

so we do offer psychological support we

18:52

have a psychologist team for our

18:56

patients and they're screened before for

18:59

any anxiety and depression so that we're

19:02

able to support them the best we can

19:04

during this process and there are

19:07

various ways for us to get to know our

19:10

patients and this is something called

19:12

feeling out of Wankel this is me and we

19:15

can learn a little bit more about the

19:16

patient before they come and stay with

19:18

us and we offer inpatient Diaries as

19:21

well so there are a lot of worries and

19:27

concerns for these patients and I think

19:32

at the top of the list but for many and

19:34

which is an unsurprising is the

19:38

prognosis and what does this mean and

19:40

can we remove all of their tumor have we

19:44

got it all out how much longer will they

19:47

live for and so we have to support those

19:50

patients and try and answer those

19:52

questions as best we can the stoma can

19:55

be something that nobody particularly

19:58

wants and so we offer some counselling

20:00

for that the scar isn't

20:03

and see from the picture is a is a big

20:05

scar and for a lot of people that's

20:07

quite unsightly and it can take some

20:10

time to look at their belly button gets

20:12

removed during that process as well

20:13

which is quite unusual too when you look

20:16

down and see there's no belly button

20:19

so the scar can be a focus for a lot of

20:22

patients they're with us for about three

20:24

weeks and then afterwards when they go

20:27

home we offer a follow-up care so we do

20:31

telephone calls at certain points to

20:34

check that the patients are recovering

20:36

well at home and eleazar their local

20:39

teams so my role probably this bliss

20:46

isn't isn't exhaustive I support the

20:50

patients often remotely not only those

20:53

that are having this surgery but those

20:56

are going through all different

20:59

treatments in the UK I would signpost

21:03

them to various teams or various

21:07

services help them with any symptoms

21:12

that they are struggling with seeing if

21:14

there are all ways that we can help to

21:16

manage those speaking with their

21:18

specialist teams and their local

21:20

hospitals and specialist nurses and

21:26

often it can be talking about the

21:27

disease itself as we said that it's a

21:31

very rare disease and they find that

21:36

they want to talk to the people who have

21:39

experiencing in this service development

21:44

so we look at how we can improve our

21:47

treatments that were offering how can we

21:51

get it known what we're doing amazing

21:54

stake so I just thought I'd run through

21:59

a quick case study with you here just to

22:01

sort of set a bit more of a picture of

22:04

them perhaps what it might look like for

22:07

a patient

22:09

this referral came in last summer a

22:12

young female and with fit and well and

22:15

no medical history and she had they used

22:18

nonspecific symptoms that we spoke about

22:21

and was bit to handle something called

22:25

irritable bowel syndrome but these

22:28

didn't resolve and so she was referred

22:32

into the hospital and she had a

22:35

laparoscopy though this was her and

22:37

something to explore what might be going

22:40

on and inside the pelvic area looked

22:43

abnormal and so there was a biopsy that

22:45

was taken and this unfortunately came

22:49

back inconclusive and so no diagnosis

22:53

could be given so she went through a

22:55

second biopsy and that was reported as

22:59

the well differentiated papillary Parana

23:03

mesothelioma and that was the one that

23:06

we spoke about us it's in the low-grade

23:09

spectrum and she was informed by her

23:12

local team that this was something that

23:14

was low-grade and indolent and was

23:20

informed that her treatment options

23:22

could could bury and it could be either

23:24

the watch and wait or pass there might

23:26

be some chemotherapy or or an operation

23:28

might be needed so her local team

23:31

referred us referred her to us at our

23:34

national MDT and we had a look at that

23:36

in August and our pathologists had a

23:39

look and subtype t as epithelioid say

23:43

that moved it over into the malignant

23:46

spectrum and we do a particular test

23:52

calling ki-67 which is is slightly a

23:55

prognostic indicator and hers was around

23:58

20% around 9% is is that normal see

24:03

moving up higher is likely more

24:05

aggressive we had a look at her scans

24:09

which sewed quite extensive disease in

24:12

the in the lower part of in the pelvis

24:14

and their personal linings and also on

24:17

the diaphragm linings and we we

24:22

suggested that she'd

24:23

should consider some fertility options

24:27

and we had a look at the DVD from the

24:30

laparoscopy that was done in her local

24:33

Astra and it was quite difficult for us

24:34

to have a look on us to see the small

24:36

bowel and see if there was any disease

24:37

there so we decided we'd offer her our

24:42

patients appointment and we would do a

24:44

laparoscopy here at phasing snake and to

24:47

assess the disease so we did that in

24:50

October and it was decided that her

24:54

disease was operable and we'd be able to

24:56

achieve that full sight reduction and

25:00

that no bowel resections would be needed

25:02

and she'd in the meantime seen her

25:06

fertility team and her successful egg

25:09

collection so in November she had her

25:14

operation she had the CRS and HIPEC

25:17

treatment as you can see there there was

25:20

disease in quite a lot of areas we

25:25

removed peritoneal linings on the left

25:28

and the right and the immense him which

25:30

was that fat apron we removed her spleen

25:33

and she had an okay suspect me

25:36

we removed the linings of both of her

25:39

diaphragms on the left and the right you

25:41

remove the linings in her pelvis she had

25:45

a total hysterectomy a removal of her

25:49

ovaries and we did a remove her appendix

25:55

and she had a bladder repair as well and

25:59

there was a slight tear there and then

26:01

she had the Hawking therapy wash for an

26:04

hour afterwards and she had when she

26:07

came out the operation she had full

26:09

abdominal drains the right chest drain

26:12

another drain she was in the operation

26:15

room for about seven and a half hours

26:17

and with a minimal blood loss she

26:21

recovered really well after the

26:23

operation and after three weeks she was

26:25

discharged to her local team for

26:28

monitoring regularly and we recommend

26:31

Daniel scans so that was a really good

26:35

outcome for that patient

26:37

and referred to the National MDT where

26:40

we looked and she was suitable for the

26:43

full surgery and her outcome was with

26:47

successful after the operation simply

26:53

have a look into the future and what's

26:55

what's ahead of us well we we want to

26:58

continue our MD T and we will continue

27:01

that developing it looking at the

27:04

patients that have been referred over

27:06

the time and how they are doing what

27:09

treatments they received to get an idea

27:12

on on how these patients are being

27:14

treated and which ones are being treated

27:16

in which part of that spectrum in the

27:19

lower grade and the high grade we aim to

27:23

go back to NHS England with our data and

27:27

data that's been published worldwide

27:28

about the CRS and HIPEC surgery and ask

27:33

for them to Commission the surgery we're

27:36

looking at offering a prehabilitation

27:39

service for the surgical patients so

27:42

helping them to get fit and being best

27:47

shape as possible for recovery

27:50

afterwards we are looking at the

27:53

clinical trials that are available with

27:56

the systemic treatments that that can be

27:59

given for these patients and

28:00

immunotherapy is something that's at the

28:03

forefront at the moment we are looking

28:06

at something called PI Peck which is the

28:09

which is a pressurized chemotherapy

28:12

that's done at laparoscopy and that's

28:15

always a little sprayed into the

28:16

abdominal cavity and that's something

28:18

that we're looking at at the moment and

28:20

I'm watching the data worldwide and

28:23

thinking about whether we can offer

28:25

something in a clinical trial setting we

28:30

need to develop more information for

28:32

patients and leaflets and online

28:35

information and I think one of the big

28:39

things that these these patients and

28:41

their families that are asking for is is

28:43

support for one another and we are

28:47

looking at ways at doing virtual support

28:49

groups

28:50

and an events that we can do and to help

28:53

them talk to each other and share their

28:56

stories so in summary we have a look at

29:02

what we've just spoken about Paris

29:03

anomalies the MU is extremely rare and

29:06

it has links with us best exposure and

29:10

the chemotherapy is a good treatment

29:12

option which does gives limited benefits

29:15

is the palliative treatment and from

29:18

what we've seen the work that we're

29:20

doing we can achieve some good surgical

29:23

outcomes

29:24

for those patients that have been

29:26

carefully selected by the MDT thank you

29:32

a really helpful insight into personal

29:36

mesothelioma I think what you said about

29:39

just providing the support it's all the

29:43

patients but also pre and post operation

29:45

I think that will be really reassuring

29:47

some of the patients listening to your

29:51

presentation and it's also just kind of

29:55

dawned on me about the the remotes MDT's

29:58

that you you and the team have because

30:01

obviously I'm assuming those nd T's go

30:03

ahead because of geography or have done

30:05

in the past because you've got

30:06

specialists from all over the country

30:08

you've got treating patients not

30:12

necessarily in your local area and I

30:15

think we've shown haven't we that those

30:17

support group meetings as well can go

30:19

ahead remotely so I think that's you

30:21

know it's a really positive step that

30:23

you know you can hopefully start to

30:25

offer that remote support group as well

30:27

yes absolutely so I think we're going to

30:31

start our first virtual support group on

30:34

the 3rd of July which is the action miss

30:37

video today this is being done virtually

30:40

and hosted by the UK news Alliance and

30:44

I'm going to run a similar and seem cool

30:48

in the morning and for patients or their

30:51

families if they want to dial in and we

30:54

can have a chance with other people

30:57

around the UK and then that will launch

30:59

into the events that's being held by the

31:03

Alliance

31:04

breanne so I've got one question just

31:08

about the statistics that you mentioned

31:10

that the right at the beginning and of

31:12

course we see more males with

31:14

mesothelioma but what I was particularly

31:16

interested in really is with the females

31:19

the instance the peritoneal mesothelioma

31:21

is that little bit higher than for

31:23

plural and is there any reason behind

31:26

that do we know I think we could

31:29

probably have a look at those non

31:32

asbestos causes in a bit more detail and

31:36

perhaps those will mean that patients

31:41

with female patients perhaps that are

31:43

predisposed more the lower grade gliomas

31:48

the the multi sistex they seem to be

31:53

more prevalent in females as well and

31:55

there could be some hormonal link there

32:00

okay and our final question is from one

32:04

of the attendees so it's quite a

32:08

specific question that you may not be

32:10

able to answer exactly but he is at

32:13

Basin State Hospital and he wants to

32:15

know really if his CT scan is due to go

32:20

ahead in August obviously we're in a bit

32:23

of uncharted territory at the moment

32:24

what's the feeling on whether or not a

32:27

CT scan is happening as normal will it

32:29

be the stones you know what what do you think might happen yet those services are still running there are some slight delays but I think we're seeing particularly today services in the retail industry all up and running today and I think you I think we'll see a quick escalation of services resuming they're not to be too panics about an August scan and just to reassure patients that we will get through their routine scans and as as quick as we can great it's really helpful

Thank You Samantha and thank you for sharing your your time with us and taking the time out today

Many thanks for having me

 

 

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