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Hello, everyone. It's great to see you on me live this morning, uh Saturday morning. Um, today we're gonna hear about um conquering breast cancer. And, um, if you could pop your questions in the chat, we'll get those asked either throughout the presentation or at the end. And as always, your feedback form will be in your inbox and your certificate will be on your med account. Once you've filled out your feedback form, we will be passing on all the feedback to our speaker today. So please please give some really good feedback because I know our speakers really like to hear back about how they presented and that kind of thing. So please do fill out your feedback form. So I'm gonna pass you straight over and, uh, we're gonna learn a little bit about conquering breast cancer. Thank you. Absolutely. So you can start. All right, can I go ahead? Yes, please. Yeah, good morning. Um, ladies and um, I'm a ladies and gentlemen, I am Doctor Ali Mohammed, a fellow, a medical doctor by professional and a fellow of the West African College of Surgeons General Surgery. I'm practicing in Nigeria in Federal Medical Center. In northern, in northwestern parts of the country. I am glad to be with uh you this morning and this uh wonderful workshop organized by uh medical education. Uh the as you can have, as you have already heard from the uh uh see who introduced uh the topic. The line objectives of this uh topic. Con breast cancer is uh to provide comprehensive knowledge uh of breast cancer treatment. This aim to provide participants with up to date information on the spectrum of breast cancer from uh surgical options to advance uh therapy. Second, objective is to develop skills in multi care coordination and uh thirdly to enable effective patient education and advocacy. Now, I will uh I want to discuss this topic on the uh different outline, brief, brief anos me, then the symptoms sign investigations, multi approach, patient counseling, uh patient optimization down to uh conclusion by way of introduction cancer is genetic disorder caused by a mutation that are for most part acquired spontaneously or induced by environmental insult. It leads to uncontrolled uncontrollable growth and proliferation of causing detrimental, local and systemic effect. So when this effect, when this pathology is affecting uh breast part of human body is done as breast cancer. Uh overall, the incidence of breast cancer is rising in most part of the countries. Worldwide incidence varies from 9.3 per 100,000 women in Europe in eastern Africa to 87.7 per 100,000 women in Western Europe and uh are high in developed uh regions of the world, except in Japan and in most uh part of the developing regions. Though even in this part of the world, we are seeing the increase nowadays. But unfortunately, we don't have uh up to date uh data to uh publish to the world. Breast cancer is the most common site specific cancer in women and is the leading cause of death from cancer. For women aged between 20 to 59. We look at briefly the anatomy of the breast. Uh what we can see here here on the uh left, we can see that breast tissue is a, is a subcutaneous uh uh organ and it extends uh medially anatomically immediately from this tunnel uh and laterally up to the age of the pectoralis major. And there is what we call axillary tail that extends up to the anterial fold of axilla and the most tail in it that is connected to the fatty fat and the lymph nodes drain is much seated into the axilla. There is a a nipple area complex which is a uh a different thing with hyperpigmentation and, and uh uh and the nipple here, the ala is, is usually hyperpigmented and the nipple here that is where the uh ducts are open, the s the ducts are open for uh breastfeeding. While on the right here, we can see the anatomy dissection of the breast. This is uh lo and then this uh duct, this is good to know that the development of this as you can see is enhanced by specialized uh hormones. The progesterones are the ones responsible for the uh local development. While the gens are the ones responsible for the ductal development. So over time as the poverty uh approach is the, the breast will be developed and then it will develop into this shell. The whitish uh uh the white strand that we can see here. The white strand that we can see here are the suspensory ligament and these are fat are part of fat, subcutaneous. This is scan uh I mean this is the skin and then of course, these are the uh glandular functions of the breast. These are the uh ribs and then this is uh internist. Uh major. Yes, lymph uh drainage of the breast is very, very important because that is the pathway in which breast cancer follows. These are the lymph nodes, these axillary lymph nodes that are divided into groups, anterior groups, posterial group, lateral group, median group, central group, and ethical group. And this is the supraclavicular level and infra I mean infraclavicular lymph nodes group and the supraclavicular lymph node groups. The metastasis of breast usually follow these uh lymph channels. And that is how we classify the lymph. Uh I mean the breast cancer into uh 10 stage and into N one lymph node stage. Uh stage 123 surgically of surgical importance the lymph nodes are classified into three. This is group three groups rather group one lymph nodes, group two lymph node, group three lymph nodes. So usually how we identify them. Usually the group, one lymph nodes are below the uh pectoralis minor. This structure that we are seeing called blue is pectoralis minor. So the lymph nodes that are below and later to the pectoralis minor uh term group one lymph node. While those behind the pectoralis minor atom group two lymph node. While those above and immediate to the pectoralis minor at as a uh group three lymph nodes. This is of surgical importers. Breast development and function are initiated by a variety of hormonal stimuli including estrogen, progesterone, prolactin, oxytocin carat, hone cortisol, and proton estrogen progesterone and prolactin especially have profound tropic effects that are essential to normal breast development and function. Estrogen initiates ductal developments where I whereas progesterone is responsible for differentiation of epithelial and for lobular development. Prolactin is the primary hormonal stimulus for lactogenesis in late pregnancy and the postpartum period, it up regulates hormone receptor and stimulates epithelial development. This essentially shows the main hormones that are responsible for breast uh development and growth in breast. This uh diagram briefly depicts what we have just said. There are a lot of stimuli that, that help that do occur. This is anterior pituitary. These are the various hormones that are secreted from the anterior and the pitu three but precisely those uh that acts on the breast, the cortisol, the growth hormone that we mentioned for the uh piel development, but precisely the ductal development. The estrogen, the low blood development, the progesterone and the uh uh the the prolactin for milk like and oxytocin. Of course, we know the importance in uh breastfeeding. Now, specifically the course exact cause of breast cancer is not known. However, there are a lot of factors that are known to be risk factors for breast cancer. These risk factors are divided into hormonal risk factors and hormonal risk factors. The hormonal risk factors include increased exposure to estrogen. It is usually associated with increase of develop of developing breast cancer. Whereas a induction in exposure to explosion usually is protective. The increase the decrease in exposure to estrogen that is known to be protective for breast cancer is usually uh uh uh uh age at early uh first pregnancy, around 18 years of age. Uh uh pregnancy are breastfeeding that is up to 18 months, 18 months, breastfeeding, day after and then uh adequate number of uh parity. While those all this will reduce the exposure to estrogen, it reduced to expo. I mean it reduces exposure to s in in the sense that during pregnancy, there is no stimulation to the ovary, the estrogen uh and I mean no cycle. So the level of estrogen will reduce. So the stimulation of the breast will reduce during breastfeeding. Also for a long period of time there is a breastfeeding, amoria, the exposure to estrogen is is also reduced and when pregnancy is between 2 to 3 years thereafter, also, the exposure will reduce while those that have increased in uh increase in um uh uh increase in stimulation to the breast. Uh cases of uh any any men and uh late menopause, no parity and lack of uh breastfeeding and no order. So, the non risk factors include radiation exposure, chest radiation, alcoholism, obesity, cigarette smoking, genetic and familial uh factor factors. So this table briefly show the uh risk factors that will just mention some of them, these are risk factors that can be modified, increased age, female gender, uh no parity as you mentioned earlier among others. While those that can be, I mean, those that can be modified uh uh the the parity level of breastfeeding, obesity, those can be controlled and other risk factors, of course, uh that are histological risk factors in cases of benign breast disease. So it's good to know the sporadic familial and hereditary cancers that sporadic breast cancers usually are the highest that one, meaning they are larger percentage of breast cancers are usually sporadic up to 65 to 75% 15 million 20 to 30% while hereditary are usually less than percentage. So, among the hereditary breast cancers, they are see one, they RCA one 11 mutation is account account of to uh 45% of the cases. While BRCA two gene mutation account up to 35% of cases of uh genetic causes. Now it is good to go straight to do our discussion. I try to make this this discussion. Uh patient patient base uh management rather than more of academic. So what are the symptoms that this patient commonly present with this patient? Patient with breast cancer commonly present with symptoms as follows low original symptoms. Uh endless breast m is very, very important. Usually patient that present with pain, painful breast swelling or painful breast lump at up initial, it is usually unlikely to be breast cancer. Rapid progression is a character of breast lump and ulceration. This breast lump that appeared 12 months as a patient s can ulcerate within a short period of time. Then some skin changes can be apparent darkening uh uh uh of the skin ulceration. Pre results of uh orange like appearance of the skin that we call nipple changes. Either nipple destruction, nipple retraction can also then it's later axillary or periclavicular from the patient can easily notice that she has a fullness in the uh in the in the axilla or in the peri um peri clavicular uh and then occasionally when the uh axillary swelling is advanced, patient can have associated with swelling. Now, some of them can present with metastatic uh features, especially this part of the wall, that patient tends to present legs due to several factors. They can present with anorexia, body weakness, indicative of anemia. They can also present with, with uh weight loss or weight loss is not marked in breast cancers. As we usually see, they can present with features of brain metastasis, persistent headache, dizziness. Sometimes they could present with features of chest metastasis. Uh that is characterized by cough, difficulty in breathing. Sometimes they could present with disc of the eyes, suggestive of liver metastasis or they could present with a suggestive of ascitis or long bone pain and deformities, suggestive of pathological fracture or metastasis to the bone or sometimes back pain and even paraplegia when there is metastasis to the spine. Now, on general physical examination, after, after taking full history and looking out for the risk factors uh from hormonal genetic familial and then hearing the symptoms that are likely to be suggested the local sys symptoms, the systemic symptoms. When you have to examine, what are the important things that we should look for in patients with breast cancer, things that we have to look for in patients with breast cancer. On general physical examination, look for anemia, it could be anemic. So they could be pale and then they could have a disc of the eyes which is jaundice. In advanced cases, they could have fever when there is uh uh of course, breast uh uh breast ulceration with uh uh f discharge discharge when sepsis has, has a a certain as presentation. This patient could have fever, then locally they could have skin changes that could be very obvious ulceration, uh various nipple changes and bloody nipple discharge can be seen on the breast examination. Usually the mass palpable if not ulcerated could be heart irregular, poorly defined mass. That's the character of uh malignant mass. Usually if it is so a lump from breast cancer is usually soft or f it is usually well encapsulated and then it is usually mobile. While in breast cancer is really hard, irregular and poly it, it can be attached to the ovarian skin on the left shows or both. Then its lateral axillary or periclavicular infraclavicular or supraclavicular opathy can be found systemically is also good to examine um the systems that could be affected uh when the breast cancer is adverse. And these systems are the central system uh to check for um uh assess for features of metastasis just to look for uh reduced air entry d proportion note or sometimes to need proportion, not in cases of uh low fibrosis from parenchymal metastasis or sometimes uh pleural efficient from uh uh uh dele metastasis, abdominal examination. Very, very important to look for signs of liver, uh presence or absence of ascitis, including vaginal examination because they could have from abdominal examination, they could have gal who came back to which is the metastasis to the ovary. And they could have uh what, what you call when the metastatic deposit uh landed in in the report. That will be picked by digital rectal examination. Musculoskeletal examination is also very essential. As we have. Rightly said, this patient could present with metastasis to the musculoskeletal and sometimes even this time. So patients should be asked to walk before then. Uh spine should be examined fully for presence of uh gibbus and then also some deformities. All right. So on, on the examination is this uh uh diagram debate um position for examination. Usually uh patients should be asked to stand with her hands or to sit with her hand by the side. Then breasts should be look uh should look at and examine the per region, the skin for any changes, any ulceration, any pain, any period range, the patient should be up to uh her and all this one on on on inspection. That is the diagram here on this side. So the axillary fullness should be looked for uh the sense of the breast. Everything could be look for sometimes in uh breast one to raise the blood. I mean the breast aspect, the lower aspect usually for completion and to ensure nothing is missed. We do systemic quadrant, breast examination. So as not to miss anything. So this is called by our usual clinical examination. We do divide breast into five regions. So this is outer quadrant where my is showing, I don't know whether I'm uh visible and then the uh all the audience can see the screen. This is upper outer quadrant this is lower outer quadrant, lower inner quadrant, and then this is upper inner quadrant. So, so also here and then this is areolar complex. So we systematically from quadrant to quadrant looking for that is when patient usually put patient, not in this position but to nine and 45 degrees. Uh uh go that is in cardiac position. And then we follow systematically to palpate with come the palm of our hands, uh the palm, palm of the fingers to palpate. Then of course, the nipple, a complex loss. And then we expect to see if there is presence or absence of any uh bloody nipple discharge. So these uh are clinical photographs of some of the patients that we see. Uh a lot of them do present in our facility like this late presentation because of several uh belief, this is uh from getting calling flower uh that uh within six months, the patient has it. But uh she presented uh uh after this, uh of course, she has a uh axillary lymph nodes. Uh And so we took her biopsy and the stress and the histological motivity and they ductal carcinoma. This is also another patient that have uh initially what looks like inflammatory uh breast uh cancer. She presented also late here as you can see already, she has um uh uh cancer inclusive, all these uh deposits. Uh cancer, of course, she has uh a lot of axillary lymphadenopathy. Yeah. After after clinical examination local examination and systemic examination. The next thing to do is to investigate and these investigations, we consider these investigations into this. We investigate for these purposes. The first proposal of the investigation is to confirm our diagnosis and the way to confirm, I mean, the investigations to confirm our diagnosis, we do tissue biopsy. This tissue biopsy is the gold standard. We do histology under this tissue biopsy that will take either two biopsy or a or biopsy. In the case of ulceration. When a patient is ulcer. Well, if it is normal without ulceration, we do to biopsy. This biopsy, we take tissue and this tissue will show the histology of the tumor. Whether the tumor is uh uh uh lobular carcinoma in situ lobular ca or, or ductal ca insitu or invasive ductal or invasive lobular cast or other even R cancers like uh papillary, medullary and uh other nonspecific uh R cancers. Then tumor grade. It will show whether the grade of the tumor is well differentiated or poly differentiated. A very important therapeutic and prognostic factor. We subject patient to immunohistochemistry that is uh to know the the receptor status of that particular breast cancer, whether it's estrogen receptor positive, uh pro receptor positive or human epidemic growth factor receptor, two new positive and also ki 67 which is a, a marker of proliferation of the uh breast disease. This is very, very uh uh importance of course, as the outcome of immunohistochemistry will be of help as far as management is concerned. So other, other um uh uh molecular testing that are currently in use are oncotype DX and mammaprint. These are molecular biological tests that are commonly done to know whether particular tumor can benefit for chemotherapy or not. Especially in patients that have immuno, I mean estrogen positive receptor, uh that's usually will benefit you with hormonal therapy. So commonly combination could be done sometimes for patients with uh low risk of recurrence. The use of chemotherapy might not be uh necessary as the oncotype DX might show, uh, uh, uh the value the high values of DX might show that this investigations are usually, those investigations are usually not common in our environment. Other, uh, confirmatory tests that could be done, uh, ultrasound for those that have breast lump, those that are age below 30 I mean below 35 years of age because of density. While those above 35 years of age, we do uh mammography, mammography will be good in those above 35 years of age because of a reduction in, I think we might have lost our speaker, but I'm sure he'll come back again. Ok. Just bear with everyone as always if you've got any questions, pop them in the chat. Um, and hopefully our speaker will come back. I can't fill in as you all know, I'm not medical, but he will come back, hopefully. Um, I don't see him yet. So just so that, you know, our speaker today was actually from Nigeria um beaming in live. So as you can imagine, there could be internet issues. Um I don't really have anything else to say. So we'll give it a couple of minutes. We'll see if he comes back, if he doesn't come back. Um, what I can do is I can either reschedule or I can ask him to um record and we can let you have that recording. To be honest, this has never happened on medical education. So I'm not really sure what we're gonna do. It could be the internet has gone down in Nigeria completely or just where he is. Oh, thanks Isabel. Um He hasn't gotten back to me. I have emailed him. He hasn't gotten back to me. Um So I'm gonna assume that there's something wrong with his internet. Like I said he was joining us from Nigeria. Um So I think, yeah, so is not to the rescue. Let me tell you she doesn't have a medical background at all. Um Yeah, I think, I think we've lost him. Um but we'll get something sorted. Uh Like I said, we'll either reschedule or we'll ask him to do a video and we'll just add it as catch up. So you will get this talk. Um But I don't wanna keep you here on a Saturday. Oh, hang on. Hey, hang on a second. Bear with everyone. Bear with. Are you, are you there. Yeah. Yes, thank you, everyone. Hey, we got you. Yes, we got you back. And the only thing is, I mean, what happened at your end? Have you got internet issue? Yes. It's like, um, uh, uh internet, uh, issues. I realized at a point in time I was asking that II had some sounds actually, but I could not, uh, nowhere specifically, people could not hear me. So I decided to check my phone to see how far. So, so I don't know, I don't know. How far, how far have I gone? Maybe was it north earlier until later or from the beginning? It was not scared. Um, we just lost you. Um I'm not actually sure what side you were on but um, oh, I did see a number but now I can't recollect. Let's see if anyone in the chat can help. Who knows where we've got to. Are you on your phone though? Cos you'll not be able to share your slides on your phone and I don't have a copy of them? Yeah, maybe, maybe. Let me, let me share the slide again with my, let me, you're on slide 18 investigations. You've got some keen people listening in here. The one with the tissue biopsy is a gold standard. That's where you were at. 00, all right. That's great. That's good. No pressure. But they were listening. So let me, let me, let me, let me check actually to see uh, how many, how many shots? Yes, ma'am. Yes. Yes. Any sweets. Great. So, no, maybe I might have to go back to. Ok. So let me see again. All right. Are you coming on on your computer? Yeah. Yes. Yes. I'm on my, on my computer. I'm trying to, I'm trying to, uh, I'm trying to share, share the, from my computer. Ok. So you need to come. Are you in the event yet? On your computer? Yes, it is uh already on. But I'm just trying to see whether it can continue or, or I might have to go back for the sharing all of that again. Well, let me, let me just see. Must I stop, stop the sharing before, before proceeding or I can, I can just, I can just proceed first scale. Mhm. So you won't be able to share your slides on your phone and at the minute I've only got you on your phone on this call. 00, all right. All right. All right. So let me try sharing on my phone. It won't work on your phone. You need to share on your laptop. And at the minute I don't have you joined on your laptop, you're joined on your phone. So I need you to go to your laptop and log in to the event on metal. Come on to the stage and share your slides on your laptop. All right. All right. So I should go back again from the uh like a previous uh process. Yes. Yeah. So go into the event, join the event. All right. Come on to the stage. Yes. OK. We're going there. All the delegates are now gonna be thinking that it's really hard on metal. It's really, so I I'm doing, I'm doing, yes, I'm doing the stage now. OK. Are you, are you, are you in the event on your laptop? Uh Yes, I'm doing the events now on my come on. OK. Turn your Yeah, perfect. And then we want your camera and your microphone on on your laptop. Perfect. OK. Now we you might wanna turn your phone off or I II. Yep. Fine. I OK. Now we want you to do present now down the bottom. Those five circles, click on present now. OK. So I can go to prison now. Yeah. Yeah. Sharing screen. All right. And now let's get your powerpoint back. Oh And what we'll do is we'll just cut this bit out of the ketchup. It's gone. Perfect. Yeah. So I can minimize this and go. So everyone was this the page that we were on? I need someone to say yes or no to this. So was this the page we'd got to everyone before we No. OK. So go back a bit more. We do it slowly slide 18 at there. This one everyone, everyone happy with slide 18 and we'll go from here. I'm waiting on a Yes. Yes. OK. Oh no. Christina says no, but it most people. Oh, a few people. Yes we're gonna go with. Yes, let's go from this slide here. Is that alright? All right, perfect over to you again. All right. Yeah. All right. Sorry, sorry everybody for the glitch for the technical glitch um to confirm the diagnosis uh is a tissue biopsy. The gold standard is histology. We look into the histological type of the tumor. The the grade of the tumor and immunohistochemistry of prognostic of diagnostic and prognostic are importance. Then uh other uh investigations are the the the uh breast ultrasound scan in younger ladies and uh the uh mammography in um those that are above the age of 35. So uh adenocarcinoma, as you can see on this table on the right adenocarcinoma is the common um I mean invasive uh uh uh invasive ductal carcinoma is the commonest type of tumor that we commonly see. No, virtually in all part of the home, even here in uh Africa region. And then these are other variants. So the importance of immunohistochemistry we can see is here we call this luminar A. This is uh molecular classification of breast cancer. This is luminar A, this is Luminal B, this is triple negative, I mean these are cell cell like otherwise called triple negative breast cancer. Then two alumina A AAA is her two neu receptor is negative while for the diabetes is positive and progesterone could be positive while 32 negative, all the receptors are negative. While for her two neu is uh usually estrogen negative progesterone negative. While the her two neu positive, that is what is called her two neu. This is very, very important in managing the patient. As just patient with a positive estrogen receptor, you know, they can benefit with either anti I mean anti estrogens aromatase inhibitors or commonly uh estrogen receptor modulators. Now, other important investigations are those investigations to stage the disease. As we earlier said, those some patients can present with advanced disease features of metastasis to to so to investigate in order to know the extent of the disease, your chest X ray, it shows features of metastasis that can manifest with either pleural effusion color b occur within the lung, parenchyma or osteolytic lesions on the ribs, abdomen, pelvic ultrasound scan can show ascitis and lymph nodes, uh mesenteric lymph nodes, enlargement or even some metastatic deposit on believe. So also CT scan which is more precise can show a lot of this. We call it uh request for the most part. I mean, in most case though it's not standard but because of the um that we have in our environment, poverty and uh inability of uh these facilities, then it is good also to do skeletal survey, especially in those patients that have uh some features or some symptoms, some complaints of uh low back pain, some complaints of uh bone, uh you know, long bone pains and uh deformities. Liver function test is also uh good in order to stage so us to assess the changes in the uh liver enzymes that could suggest metastasis. Other investigations that we do is to prepare this patient for treatment. And this treatment will either be chemotherapy, new adjuvant chemotherapy surgery or radiotherapy or sometimes any hormonal therapy. We need to prepare the patient. This investigation, electro full blood count virus serology which entails uh Hepatitis B virus, uh uh Hepatitis B virus such as antigen, anti hepatitis C virus, and then full blood counts to assess the motion two microscopic culture sensitivity, especially this patient that may have chemotherapy. And it is found that when chemotherapy is giving those people with a warm infestations, specifically sarco, they could get to have a invasion or dislodgement of those parasites into the blood and with subsequent uh central normal system. And thereafter, so these are the essential investigations that we do to prepare patients for treatment. If there is any treatment, then we got it following history, physical examination and investigations. We tend to classify as stage uh briefly about this. But to make it simple and easy is just showing the TNN stage and standard TN stage as accepted by uh American Joint Cancer Committee. This is to show that when we see T one and when there is two more that is uh less than two centimeter, we call that tumor to be T one when too low uh is uh between 2 to 5 centimeter. We did that too low. Uh T two and we went to more is more than five centimeter. We call that tumor in size. We call that tumor. We term it as three as at three while for tumors that are any size, any size of tumor. But with skin attachment or attachment to the underlying structures or both or yes or both of them, we tell that uh uh T four other ones. Uh TX means the tumor cannot be as assessed while t, not, no evidence of while TI S these are either P disease or no carcinoma. Uh uh In this is briefly what the classification uh is talking about. Of course, T four D is time T four D when there is uh when it is inflammatory breast cancer. Now, for nodal metastasis, uh N one, we call the tumor, I mean the metastasis to be nodal one metastasis. When the metastasis involve level one and uh uh lymph node while it's at 21, it is 71 and two, axillary lymph nodes that are clinically palpable and fixed. The T, the N one usually is single while the L2, I mean N two is usually fixed while the N uh uh uh N two and two is usually fixed either level one or two. And this is clinical, that's what c the c clinical stage. While the py up is usually pathological staging I do not put the pathological because that's just more with the pathologist since we are doing clinical assessment, mainly the C two CN two A is metastasis. The Epsom uh A uh uh a level one, level two A that are fix or while the ci mean uh N three ABC variant. This is when there is metastasis to the lymph nodes, either infraclavicular, supraclavicular or the internal uh lymph node. This is not something to be uh crown. It's just an idea when you are to stage D is this tumor. So this is group staging the tumor. Then there is, when there is presence of metastasis, we say m one, there is no obvious features of, we say uh and not. So following the assessment is we tend to classify this group into at early stage or stage. It's called early stage. When it is uh between stage one and two, there is no no uh uh metastasis and then no involvement up to stage two. Here, we, we can see the stage two, if not stage two, whereby there is A N one A and the tumor size is two B, uh stage two B usually for, for four stage. Uh I mean for group stage one A up to two, I mean for group stage from 0 to 1, usually they, they are termed as a early stage. You know, there is no features of local advancement but from group three down what? From group three A. Those are the ones with features of local advancement, others involvement or attachment to the underline structure. Of course, stage stage four is metastatic uh disease. Now it's good following assessment, staging of disease to know that cancer management worldwide standard is multidisciplinary approach. The team involved a general surgeons, medical oncologist, radiation oncologist, plastic surgeon, psychotherapist oncology, nurses, anesthetist, and palliative care specialist. This thing should come to look at what patient present with. Look at the clinical examination, findings of the patient. Look at the investigation. Is it any stage? Is this, is it locally advanced or is it is it metastatic? Then what are the treatment plan that this patient could benefit from? Would he benefit from new Adjuvant chemotherapy? Would he benefit from New Adjuvant radiotherapy? Would he benefit from surgery? First, before this multi team should sit and uh decide on the best treatment plan for patient. It is very essential and part of standard practice to carry patient along as far as treatment of cancer is concerned. Patient counseling is very, very important. It's good to counsel patient, patient should be aware of the diagnosis, the extent of his disease. The decision following what is this uh what is found to be the extent of disease? Is this treatment? I mean is this disease at presentation curable or is noncurable? Are we aiming at cure or we are aiming at P and treatment plan and side effects of the treatment? Whether adjuvant I mean, whether chemotherapy radiotherapy or surgery, what are the side effects? Then short term, a long term complication for treatment. Then the cost implication very, very important, especially in this part of the world whereby there is no NHS cover for many patients. Then what is the prognosis of the disease? And how to follow up the patient patient should have all this information at the beginning of uh uh treatment. Then uh we have to optimize I fully resource patient, especially I do emphasize in this part of the patient tends to come with advanced disease with presentation. So when they are anemic, we correct anemia with transfusion adequately. We aim at a pa of 30% or hemoglobin of 10 g per day. Then we correct dehydration, those with sepsis, they could be dehydrated, they are not taken orally correct dehydration, no recur electrolyte derangement, those with electrolyte. Then we control sepsis. Then of course, pain control. Even using opiates, the treatment mainly could be chemotherapy or cytotoxic uh therapy. The aim of uh our treatment usually when patients present after counseling, patient optimizing patient, we counsel patient that this is the aim of treatment for those patients. That could be, I mean they are present with a curable disease. We tend to offer them what we call new adjuvant chemotherapy. New adjuvant chemotherapy is the chemotherapy or therapy that is given to patients before surgery. The aim of that is to down the disease and to make an inoperable tumor operable patient can present with T four tumor. But whilst uh we administer new adjuvant first cycle, second cycle, third cycle, that tumor will be down stage two, T two, T three or T two, making the tumor operable. And the lymph nodes, axillary lymph nodes that were mark will shrink, become mobile, you know, and so that will make the surgery easy when adjuvant chemotherapy is a chemotherapeutic regiment that we do administer following surgery. So the principles of administering chemotherapy, whether adjuvant or adjuvant chemotherapy is combination. We combine, we don't give single agent. Usually we consider giving ok, alc agent with anti metabolite or we consider giving ok, anti metabolite and the tax, the aim of this is usually using single agent can prone to development of resistance. And when the system is developed in chemo, I mean in chemotherapy, in cancer patient, that will be catastrophic. And we we we also do a this as very important pro cyclical cyclical chemotherapy. We give it in cycles like uh to give one cycle. Now, after three weeks, we give another cycle. After three weeks, we give another cycle. The of this is when to most are kill, others will be brought back into circulation so that they will be accessible to the chemotherapeutic agent cells that are in gen in the sense that are usually by stage, they are not a amenable, they are not accessible to the chemotherapeutic agent. But when the cells either in S phase or in N phase or in any other stage. That is not gen not as commonly um targeted or killed by the agent, irrespective of the of the face of the cycle. When those cells are kill, large fraction of the cells will go down. So those in the cancer cells in will be proliferated back into the, into the circulation. So when it is given cyclic, the chemotherapy can kill this uh very effectively because it's cyclical and importantly, agent with different mechanism of action. We don't give two agents with the same mechanism of action. We give agent that that maybe either T DNA synthesis, while the other ones will target the microtubules, while other ones will target uh uh uh uh and that is the uh uh me uh micro rather. So this and then to avoid very important last dose to avoid development of resistance is to give recommended dose. We don't give 12 courses and stop. Usually we give up to 68, sometimes even uh 10 courses uh depending on two more response. Now, this is um uh from uh NCC guideline, NCC can only uh updates its guideline yearly. I will not place one on 12, 23 guideline, but uh preferably for patients. This is just what is preferred in patient, breast cancer patient with her two new negative preferably is to give a choate. Then this list followed by paclitaxel every two weeks then these are other regimens that, that will be given cyclophosphamide five fluorouracil while for two new positive uh patients adamycin crops them to be followed by. So these exams will either be or do. So it's always good uh to refer every time to uh the current implementation as far as NCC guideline is concerned. And since we have a person that is multidisciplinary as a surgeon, it's not you that do test alone, you have to involve the medical oncologist and the radiation oncologist as well. Now, for surgery, surgery treatment, uh surgery remains the best treatment or the gold standard as far as treatment of uh breast cancer is concerned. Generally, all the tumor surgery is domestic breast cancer include it. So the common uh surgeries that are being done now is either uh breast conserving surgery, simple mastectomy, do simple mastectomy is discourage your sophomore or modified radical mastectomy, modified radical mastectomy is when that a simple mastectomy with axillary and breast uh reconstruction. Thereafter, the breast reconstruction can be done at the surgery or it could be done uh at a later stage. Um uh This uh diagram depicts uh the surgical technique. The diagram on the left here shows the incision, the incision that we commonly do uh electrical incision involving the complex here that we incise, we dissect deep to rest flap, this upper upper flap. Here we raise the upper flap. Of course, this surgery is after we have optimized, we have patients, we have optimized and informed patient all the the complications, whatever just like we have earlier today. So we raise this flap on this diagram, we raise the flap here up to the clavicle, the upper flap or the lower flap, we raise it up to the upper border of the rectus fascia. Then we dissect, we take out the breast tissue from the pectoralis facia. Then we extend our dissection into the uh axilla into the axilla. We we we extend into the an as you can see, there are a lot of axillary thoracic nerve to do nerve which is left to uh to do uh cost here supplying the skin over the and then of course, a lot of vessels, the subs branches that supply the muscle here. So commonly, the, the principle of the section here is to address the lymph node. This muscle is a landmark, very, very important landmark. The retracted muscle here is the uh is a pe major while the mule here is a pe man. This pe man, if you can remember from what you describe, the lymph nodes are classified or are good according to this uh deposition of this uh me, I mean the uh pectoris. So the here group one, those behind it are group two, then those above. So this the aim of cancer surgery is to uh take out the lymph node of group one, group two and group. And that's why the radical surgeries before it takes out the, the pectoris me, the radical mastectomy is to take out even the, the, the pectoralis me the P minor as well. And even all the group of so later modifications come into be the part modification, this modification and close modification all now feel that excising thoracic, I mean uh uh uh uh this pectoralis major will add to no significance. No, any benefit as far as survival is concerned. So why uh uh why that extensive resection and predispose patient to a lot of difficulties? Therefore, they tend to deserve the pectoralis major and manipulate the, the P minor. The the m some uh detach the man from process this the att of it while some will just reflect it. So, what you commonly do now is the latest modification of radical mastectomy that is modification of whereby the man, I mean major is left intact. The the man is also left intact. Then the axillary group will be uh uh I will be, will be dissected, finger dissection here, you know. So as not to injure the axillary artery, which is usually the landmark, the upper part of uh axillary this intersection. And then also to dissect, I mean to evaporate uh the lymph node behind the tumor, which is the group group, two lymph nodes and then the lymph node that is above and median uh to the pectoral, which is the group by reflecting using this uh to the tumor node that can be done to Eva on the lymph nodes. So when those lymph nodes are evacuated and the breast tissue has been taken completely. It is believed that uh uh curative resection has been offered to patients that are having uh breast cancer. This clinical photograph is a patient that I manage with a young lady with right breast cancer for. So, surgery that we described. This is uh what will happen in this young uh lady, the surgical dis to be uh free merges. We have, we are going to averse from the groups of lymph nodes in one, group, two, we are going to a up to 12 lymph nodes out of which only one not appear to be positive or a negative. Then the merges of the a resection, the superior in the deep margin were all negative. So other important uh management that is being recommended now is a breast conserving surgery and breast conserving surgery is found by many clinical trials to have equal outcome uh with modified radical mastectomy that we have outlined. However, in this case, patient must come early for patients that present early without features of without features of local advancement or systemic advancement, they can benefit from breast surgery. But following breast surgery, they have to go for of course radiotherapy and this is when the breast size is adequate and the breast lump, the breast cancer is not uh uh uh has not applied, you know, uh more than one quadrant and is free from areolar uh complex. So, the aim of doing breast conservation, like we can see here is to conserve the breast. As uh nowadays, a lot of uh ladies, young ladies usually don't uh usually consult for modified radical mastectomy and it give uh virtually so no need to do where you have the facilities of radiotherapy and the expertise. So yeah, this is lumpectomy, the breast cancer, this one has been taken out and then the margins were leveled. So this is how to level the margin. The in uh the the uh this is um uh superior margin, infero margin, natural margin, region, margin, the deep margin and the superficial margin is essential and very unnecessary to level this margin. So that the this can have a look at it. The pathologist can have a look at it and now give the findings or report whether uh if there is involvement of tumor in any of these uh mas. Now, radiotherapy is a component. Uh it is an integral component of uh breast cancer management. This radiotherapy uh uh is usually given adjuvant uh following modified radical seal or breast conserving is good to have uh external beam radiation. Maybe the radiation should be given to the chest wall and then to be given in the fractures. The principle I've given chemo, I mean I given radiotherapy is to be given after the surgery and following surgery or a modified radical mastectomy to be given after the surgery, to be given in fractions to be given to the chest wall and the supra region in most centers, it tends to target an average dose that is not um helpful to the patient. 53 that is targeted. This 50 degree has to be given over five weeks. That is 10 degree every week and it is delivered to three per day for five days from Monday to Friday. Then patient can rest for Saturday and Sunday. So for five days, uh two days, just 10 and for five weeks, that is completely 35 uh yes, that five days and that's making they tend to do well, you seem to have some uh minor side effects, sometimes major. But the, I mean, the radiation oncologist usually optimize them before the uh procedure and then they tend to look for complications and the complication appropriately. Just contraindication. If you do the modified radical mastectomy with the surgery that we have described, and when we uh evaluate the axillary lymph node, we it is usually contraindicated to radiate the axilla. Therefore, we, we give them the details of the operation that we do, then they consider the radiation only to irradiate, the uh supra and infra region. The reason is that when you irradiate the ana the remaining lymph nodes that are there that are in the uh when I radiate uh the zena, those lymph nodes can be damaged. Therefore, the patient can develop huge and very disturbing uh ipsilateral uh lymph edema, hormonal therapy is an integral and very important part of uh the therapy we have mentioned in the immunohistochemistry will look at the uh hormone receptor status. Whether estrogen or progesterone positive. We have seen that in in the ology that estrogen is responsible for doctor of the breast. And then we have seen in the histological time that the commonest type of tumor is invasive ductal carcinoma, not invasive lobular carcinoma. Therefore, estrogen is very, very important uh hormone. Therefore, the treatment is usually targeted against estrogen for those that have what estrogen positive uh uh uh breast cancer for those that have negative estrogen. So this this might not be useful. So this is useful in those that have estrogen positive uh you know receptors. So we use uh commonly used selective estrogen receptor modulators which is uh tamoxifen. That is the one we commonly use or it's a don't know sometimes uh uh is not commonly available in our environment. So must be use this tamoxifen and this tamoxifen as therapy can be only therapy that is needed when full patient evaluation has been done, especially where the facilities where there is a presence of uh like that we discussed uh only the tamoxifen can be adequate for the uh therapy, new adjuvant and even the uh adjuvant. Then other antigen is a aromatase inhibitor. Currently, three third generation aromatase inhibitors are approved for clinical use the reversible nonsteroidal uh inhibitors azole letrozole, oh and then the irreversible steroid inhibitor, which that is uh uh is uh is in 10. Now targeted uh therapy. Uh It is good to know that important a receptor that is found to be expressed in breast cancer is high is H epidemic receptor, uh derma growth factor receptor. Two new, that is one of the genes that are being looked for in uh in chemistry for breast cancer. And uh there is a drug that is developed, you know, to inhibit that thereby prohibiting or thereby yes, prohibiting pro progression of breast cancer. And the common one that we use in our, our our environment is has a change that is tuum or uh deab. Of course, there are other ones that are developed their analog, all those that complement the work, all those that complement the effect of the particular receptor because the receptor has a different component. So currently, there are a lot of drugs that are being developed to assist uh O2 years enhance the function of uh uh trastuzumab or uh uh AAB. And usually for patients that have this that just had two new positive uh patient. It tends to do extremely uh well, they tend to respond well uh with this uh therapy. Now, what is prognosis of uh breast cancer? The prognosis actually depends on presentation time from the onset. Those are present late, they have worse pro age at presentation. What you commonly see those that present at yoga is they tend to have more aggressive disease. They tend to have uh terrible histological uh findings like uh uh triple negative disease and they tend to have bilateral disease. So they tend to present with uh worse prognosis. Then lymph nodes status, those are present with uh already lymph node, metastasis A one N two or three tend to have worse prognosis. Then histological uh attack those that have three negative or poorly differentiated uh uh uh adenocarcinomas. Basic doctor usually have more sclerosis, molecular status status. That is when somebody have, I mean, those are three negative that you can't give any adjunct apart from uh chemotherapy and uh uh surgery. Then uh then radiation therapy, SCS presence of distance, distance metastasis at presentation is also prognosis. Then those with genetic mutation, there is a one BFC uh to do that uh have imminent uh development of breast cancer or the associated uh cancers. Therefore, even after treating breast cancer, the gene can also uh I mean, they might also come down with uh other cancers. How do we prevent uh breast cancer? So I classify this into primary. So the main primary prevention of breast cancer is a health education in our environment. A lot of people are like, you know, so you try to prevent, I mean, present a very, very uh uh let so uh way to prevent it primarily is to avoid um modifiable risk factors those risk factors of breast cancer that can be modified to avoid them is a prevention like avoid absent from alcohol and control obesity. Uh no, not reason h contraceptives and chest, I mean exposure to, to chest radiation as much as possible for non modifiable risk factors. Uh There is concept of risk reducing prophylactic mastectomy or ovarian ablation. Those that are found to have BRCA one mutation in particular, almost 100% of them might develop will develop breast cancer. Effi. So, the way to prevent that uh breast cancer is uh by giving uh uh prophylactic mastectomy. Though this is risk induction protic mastectomy. It is believed that it said that the mastectomy sub mastectomy for this prolac sub mastectomy usually does not take 100% of the breast tissue. There are still a rem. So some argue that the remnant of the breast tissue could develop. You mentioned. Uh yes. In, in, in, in, in, in, in discussion like this, I know you're still alive, we can still hear you. The internet is just pushing out a little bit. All right. All right. I II don't know whether you can hear me. I can hear you hear from here, loud and clear. Yeah, we can still hear you. You're OK. All right. So, so I'm uh I'm uh these are, these are some of the preventive measures then uh to increase the protective uh uh uh factors. I mean, increased protective uh factors. This is like uh improvement in in this in productive lifestyle resulting in less exposure to uh estrogen. As we have mentioned earlier, um um parity, breastfeeding pregnancy, all those are preventing then secondary prevention. Here, health education, regular self breast examination, screening mammography. In those from 40 years, it was uh 50 years down to 45 years now exceed to 40 years and ultra in younger individuals, those that have high risk. Then uh early presentation to the hospital, the aim of secondary prevention is not to prevent the development of breast cancer but or rather to uh prevent the development of its complications. So any presentation does end of secondary prevention, then uh challenges I want to uh mention this. Uh second to the last I think my slides, the challenges in West Africa. Uh so region, these challenges in this part of the world include uh ignorance, ignorance, uh uh uh covatine. Yes, uh ignorance, poverty, wrong belief. Uh you know, because of the ignorance on poverty, people tend to present uh late. Then there is wrong belief. As far as the, as the uh press consensus is concerned, some I have not even believed that uh it's something that can be cured in the hospitals. So high, high number of he has, we have a high number of uh he knows that people with cancer has breast cancer or other cancers do go to them to, to select before they come to a select present in a special in all the relevant disciplines, disciplines that we mentioned that are responsible for caring, breast cancer are inadequate in this part of the world, inadequate tertiary health institution is another challenge in this part of the world. Inadequate diagnostic and staging diagnosis and treatment facilities is another challenge then grossly insufficient or lack of molecular diagnostic facility. In many centers, even the so called centers are not, those are not available. So they contribute in in patient uh management in ma in many, many of our centers before one gets uh uh histology results, patients have to stay for 23 weeks or even one month. And after the histology result is is out, uh some patients might have to stay for uh additional treatment before we get uh immunohistochemistry uh results so that grossly affects their management to three motivating. Of course, the cancer will progress and high level of corruption in our government and lack of a political will. So in conclusion, breast cancer is the most common malignancy affecting women worldwide and one of the leading cause of cancer related incidents rising all over the world. African countries see more of a young patient with more aggressive disease. There is a great technological advancement in diagnosis, investigation and treatment of breast cancer over the recent years. Consequently, significant improvement in mortality has been achieved. More fascinating innovations in breast cancer management are expected in years to come due to ongoing highly specialized research in molecular biology and with the advent of artificial intelligence, then lastly, I want to conclude by saying African countries are still lagging behind due to ignorance, poverty and handling of our corruption in government. Thank you all for listening. That is wonderful. Thank you so much. If you're happy to click on the um present, now, that's on the screen and it should take down your slides then right down the bottom. If you see that's perfect. Click on that, click on stop sharing. That's perfect. All right. Wonderful. OK. So what we're gonna do is we're gonna ask um our delegates if they can pop some questions in the chat. We have one. Can you see the chat there? Are you able to see the chat on the right hand side of your screen of the screen that you're on? See we've got one from Samuel. Can Breast Uss be a screening at all? You got it. Yes. Yes, yes, yes, yes, I can see that. All right. Yes, yes. Actually, this, this, this, this drawback. Actually, this uh this is, this is a drawback. Actually, it's not usually use for uh um uh it's not usually used for screening. What is used for screening is actually mammography. That is what you out like the um uh uh this, that I use here. The ultrasound here that I put is uh in a patient with uh some risk, younger patient with uh some risk of developing uh breast cancer that uh mammography cannot give uh virtually and mammography can give a false positive result for of the density of the, of the breast cancer. But uh ultrasound is not uh tool for screening. Its use is a patient. Maybe that has some risk. So maybe it is some benign breast disease or some familial risk that they are still young. That mammography might not be able to give uh what is uh uh needed or might give a false positive uh results just to evaluate and class f or what patient might have uh either be 23 that might suggest uh uh something of concern that needs more and further evaluation. Thank you. OK. You are, you are still mute, Gibson, you are mute. So I can't hear you. I was even to us, I have another question. Would you say that most breast cancer cases are spontaneous? In course, pardon? So would you say that most breast cancer cases are spontaneous in cause? Yes. Yes. Most breast cancer are, are actually idiopathic. Most. In fact, uh what we see here, majority of our patients that we see a majority large number. The problem that we are having that we are trying to overcome is to have a, a written and published data, which is what we are trying to work on. But what we see here, you see majority over 70 80% all the nonrisk factors that are outlined in the lead, the patient that we see doesn't have that. We see patients with uh uh uh any, of course, in this part of our, our world age at the age, age at the first pregnancy was early breastfeeding up to two years with uh uh no use of hormonal contraceptives. No obesity, no alcohol, no, no genetic. A lot of uh risk factors are not, there are not there. Uh So a lot of uh uh the breast cancer and other cancers, actually, the exact cause is uh actually not exactly know it, it, it remains uh i, in, in most cases, so few is not uh I mean few of them uh have the uh factors based on what? Wonderful. I actually have a question. You showed an image of uh a breast that had a real mass on it, of, I don't know what it was cos I'm not medical, how long did it take for that er, lady's breast to get such a huge mass of um, I don't know what it was cells. I don't know whatever that was. How long did that take from going from a normal breast to one that was just full of, I am assuming cancer. Ok. II mean if I gave you also maybe breast with cancer or maybe a normal breast, I don't know which one. It was, it, there was a lady um and you had her, it was her breast and it had lots of um disfigurement to it. Um, and it looked like, how long did that take to go from one to the other? Oh, yes. Cauliflower mass. That's right. It was, thank you. Yes. Yes. So, so usually, um, the, the uh uh is a problem that we usually have is those patients, uh, do present late, usually within one year for like for that very index patient is within one year because of the aggressive nature of breast cancers. They tend to be aggressive matter of six months to one year. Most of them before one year, that very particular lady was before one year. But of course, before she present to us, she came from a rural area. She has been using a lot of uh traditional some, they apply to some, they drink some, they even smoke some things and apply on it, you know. So it takes within one year that the one good thing uh about it is uh it uh it was locally adverse. We are, we, we, we are commencing her on uh adjuvant chemotherapy. One good thing about it is usually when they are forthcoming, uh who is in treatment after three courses of uh uh new adjuvant chemotherapy, it will shrink significantly to something that will be amenable to surgery. That's what you see, especially if you use a line uh uh chemotherapy. What you have uh noticed we usually use for the benefit of uh some medical personnel here. We usually use the pack of, of fake regimen that is five fluoruracil cyclophos or five fluorouracil Adriamycin cyclophosphamide or sometimes paclitaxel Adriamycin combination. That is a first line, but we notice of them usually will give three fours without response. Then you now switch to second line. So sometimes in order not to delay them, especially those with disfigurement and locally advancement, we just uh switch to from the stats. We usually start with a second line chemotherapy that is carboplatin based. So we found in this car do usually do extremely and excellently with, in those patients that phase 23 courses, it will do excellent and then it will be amenable to excision as it is, I can't excise it or even if I excise it, I'll have difficulties in skin cover that will cover. But after that, do chemotherapy, it will be better. A lot of will disappear. So I can easily exercise and cover it without a wash tension. We have another question here. Uh A lot of people believe in traditional herbal medicines. Is there any truth in their effectiveness? Well, it's uh it's uh sad that actually what we have seen over time is that there is uh is uh is of no, there is no any uh effective outcome from what they are using. And incidentally, they are using a variety of things that unfortunately they don't know about, they don't know about because these are traditional um medicine givers. They don't have uh uh dosage, they don't have labs, they don't have uh even even the name of the agent. So some may use this root of certain particular tree. Some use leaves of banana, some use leaf of mango. Some use this and then patient will not know they just package either in a can in a bottle in later in nylon B and said you take this morning, afternoon, evening you this. So a lot of them some do take uh um uh certain natural things like uh milk, milk of C you know, uh urine of cel. Some uh patient confess that that is what they have been used using patient presented it. You know, we we are discussing, she said that is what she abuses. What she thought was response was was actually not response. She was saying when she was taking it, she saw that the, the breast size has been reduced. But there are certain events that there are natural history of breast cancer when it grows so much, it can start to shrink when it, when it, when it outweighs the blood supply. But people might think that is a good response from the drug. They don't know that that is natural history. So we uh actually do not get any good response as far as the uh use of traditional medication is concerned. Um We also have what is the mainstay of treatment in inflammatory breast cancer, but I'm not sure if you've answered that one. Yes. Um uh uh even in inflammatory breast cancer theme of treatment is is mastectomy. However, patients should have uh ii mean new adjuvant therapy based on the chemosensitivity uh uh hormonal uh status. That is whether it's a gen gen receptor positive and uh whether it's her two neu positive, her two neu positive will do well in trastuzumab while the uh er positive will do well on uh uh tamoxifen but ultimately, they will need a surgery eventually and subsequently radiotherapy. OK. And Isabel says mammograph is used for screening in many countries but it is not so safe. So safety either if you have it lots of times radiation can cause breast cancer too. Um Is that right? Well, actually mammography is safe. The radiation that is known to cause breast cancer is uh is high radiation and is frequent radiation. This is once in a year and the dose of radiation is very minimal uh compared to CT scan compared to CT scan, a radiography, you know, a mammography that is done is mainly uh the X ray beam, the X ray beam that will be used in mammography. If you com compare a single abdominal ct scan, the radiation exposure from CT scan alone is up to about 500 times that of mammography that of single mammogram. So meaning one can have mammography for annually for 50 years without getting getting uh amount of dose, I mean amount of radiation exposure to an of, of that of an individual that have single abdominal ct scan. So the radiation dose is actually minimum. So there is no fail. Ok, perfect. Um Does anyone else have any other questions? Um If so you've got your final minutes ticking past? Um As always, please, please do pop um your feedback, you'll get that. You should have it in your emails. Now, please do um give us some really good feedback and I will pass this all on. Um and then once your feedback has been filled out, then your attendance certificate will be on your medal account. So, um you've got lots and lots of thank yous. Um If you look at the chart, there's lots of thank you for your talk. I think everyone was more than happy with it. Um It was a great talk, really informative. Um So, II think that's us with our delegates. So we will say goodbye for now. Um This afternoon. Well, for me this afternoon, there's also some er ophth ophthalmology events coming up. We've got six of them coming up over the next three weeks. Um Please do um attend those if you're into ice. Um And we will see you at our next event. Ok. Thank you very much. Everyone will say goodbye bye.