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Bye. Mhm. Right. H hello to everybody and thank you for joining us this evening. Um I'm Sarah Taylor. I'm a GP in Manchester. Um and I'm the GP lead for Greater Manchester Cancer Alliance as their early diagnosis GP lead and I'm also the GP lead on Gateway C, which is an educational platform for um educating predominantly primary care in early diagnosis of cancer. And I'm very pleased that Claire is able to join me this this evening as well. And she's gonna give her a story, Claire. Can I ask you to introduce yourself? Hi. Uh I'm Claire. Um I'm an Ovarian cancer survivor and I now campaign and do work with Target ovarian cancer to raise awareness of early diagnosis and also um menopause in younger women. Thank you and Charlie. Do you want to introduce yourself? Hi. Hi, everyone. Um I'm Charlie. I'm one of the event leads from. So thank you for joining. If you've got any questions, um, just pop them in the chat and Sarah and Claire will kindly answer them at the end of the presentation. And can I just tell whether we do have the slides on at the moment Yeah, I really see the slides. Ok. So I'm just going to start um putting this like with just going through some of the figures on ovarian cancer. The majority of this talk is actually about how, how you might diagnose ovarian cancer in primary care, which is quite a difficult thing to do and, and there are quite a lot of potential pitfalls and um but hopefully some hints as well as to how you can do it. So just some stats from Target Ovarian Cancer who are sponsoring this talk. So it's over 7000 women a year are diagnosed with ovarian cancer in the UK. And unfortunately, over 4000 women a year die from ovarian cancer, which is quite high. Um And that means that there are, there are 41,000 women living with ovarian cancer in the UK, if it's diagnosed early, which is the, the issue here, nine out of 10 women will survive. But actually, if it's diagnosed later, um it's much harder to treat and the survival rates are much, much lower. So there's a few things that, that just surprised me a bit when I was looking at the stats from Target ovarian cancer and things that I think are worth having a look at and, and discussing. Um, so nearly half of GPS believe that the symptoms are only present in the later stages. So almost that we're a bit doomed and we can't do anything. Um Similarly, almost half of women um wait over three months after their first visit to the GP to getting a diagnosis, which suggests we're possibly not picking up on things as quickly as we could do. And one of the other stats which you know is you can see in um replicated in other cancers. It's similar for um stomach cancer, esophageal cancer, lung cancer. That actually a high percentage, 27% are diagnosed as an emergency presentation in accident and emergency departments. And all the data shows that women who are diagnosed or patients who are diagnosed in emergency departments actually have a worse outcome regardless of their stage of presentation. Now, there will be some of patients in every category where actually their first presentation is so acute that they will go to A&E the first time, but that's obviously not the case for every patient. So I think we need to have a think about that and see what else we can do. I'm now going to just go back to Claire and ask her if she is happy to give her a story. Yeah, absolutely. Um So I'm gonna start in the middle of my story and then kind of go back to the beginning cos sort of, I suppose the headline bit with me is that I was diagnosed at the end of 2014 with um a stage one, a ovarian cancer, so very early stage. Um and in 2015, underwent a radical hysterectomy so that I suppose is kind of the end point of my presentation. But I think it's worth making that point if I kind of go back. Um, when I was 11, I was diagnosed as a type one diabetic. So well used to the medical world by the time I kind of got to this point. But also, um, a very good working relationship with my GP, I'm very much, I'd rather control this myself than have somebody else tell me how to do it. And I had a GP who trusted that if I turned up at her desk, then actually there was something wrong. Um, and actually she trusted me enough that when I turned up, this was a good few years before the cancer, um, with sort of period pain saying these periods are really bad. She listened to me, um, I went on to Mefenamic Acid and for a number of years it was absolutely fine, but towards the sort of the middle of 2013, middle of 2014, I noticed that my periods were getting heavier again. Um, I was exhausted. Uh, bone achingly tired was how I would describe it. Um I also had a niggling pain in my side and I just felt very full and very bloated. Um, and something wasn't right. I think that's the line I started with something's not right. Something's not normal. Um And she listened to me, she didn't do the classic with ovarian cancer. And goes, oh, it might be a bit of IBS. Don't eat bread for a while. She listened, she was very good. Um, and she immediately sent me off for some blood tests and immediately sent me off for an ultrasound. Um, the blood test came back. I was slightly anemic, which wasn't shocking considering that the heavy periods and my ca 125 was really low. And I think it's important to point out that mine never raised above 12 in my whole cancer journey. So, although ca 125 is useful, I wouldn't pin all your money on it as a as a. This is definitely it. I then went for some ultrasounds. I was again, very fortunate sort of a fortunate series of events that they had enough time to do an internal and an external ultrasound. Um And, and it was fairly obvious, I think from that point that something wasn't right, went back to the GP and was referred almost immediately to the hospital where they discovered this mass on my right ovary. It was probably only about a month from going to the GP for the first time till I found myself in the hospital. Um obviously various appointments there, but probably about a month to my diagnosis, which was quick. Um And we originally, the plan was to just remove the mass in one ovary that didn't happen in surgery. But even my surgeon said we rarely see them this early. You're very, very lucky to be caught this early. Um, and the luck essentially meant that the hysterectomy was the only treatment I had. I mean, it was, it was catastrophic in terms of the effect on my life, but I didn't have chemo. I didn't have radiotherapy and I'm eight years clear now and I put a lot of that down to how quickly my GP reacted. She didn't, she didn't not believe me. She didn't think. Well, there's nothing obvious. So I'm not going to kind of push this as quick as I could. Everything was very quick, even when the ca 125 came back and it was low. She kind of trusted me enough that if she's saying something's wrong, it's worth investigating it a bit. And I think a lot of that came from the fact that she knew me and she knew my medical history. I've been in the medical field for quite some time and it's obvious when somebody's not read the notes from this side of the desk as a patient, it is so obvious when somebody's not read the notes and it just makes such a difference because time matters with ovarian cancer. It's quite a sort of cliched phrase, but it's one of those cancers that whispers, it doesn't shout. You've got to be listening for it and you've got to be quick because it does mean the difference between surviving and not. I think it's 96% of people that are diagnosed early, survive beyond five years. I'm one of those because it happened as quickly as it did. Really. And I'm very lucky because of that. And I think you said when we talked just a couple of weeks ago that you felt that you benefited from being somebody who can advocate for yourself. Absolutely. And, and I think that comes from having a, a long term condition, you get very used to fighting your corner cos it's not a fight al always. But it's actually if I'm, if that's not ok, then that's not ok. And I'm going to keep coming back and being really annoying until somebody listens to me. But it's having that, that confidence and that sort of belief that actually, yeah, I do know my own body and I do know something's not right and having to kind of keep going back. Really? Mm So question here just so that, so um how long were you experiencing the symptoms before you went to your GP? So the heavy periods was probably about six months because I was doing that classic woman thing of just crack on and get on with it. Um The, the pain and the bloating probably just a couple of months to be honest because it was so uncomfortable that it was, it was really inhibiting what I could and couldn't do. And my blood sugars had started to respond a little bit as well. And for me that's always a, no, we're not going to do this. Let's go and get it at this time. So, yeah. And are you happy to share what, what your favorite way of winding up? Particularly, um, some doctors is, I'm not a horrible person. I feel I should. However, because I've obviously had a hysterectomy and this is a classic example of people not reading notes quite often, especially male doctors when I'm about to have a test will go. Is there any chance you could be pregnant? I really enjoy telling them now and watching how quickly they go pale. And that's not me trying to be horrible. And actually we do have a laugh about it, but it's a, I respond to that with humor, other people might not. And I think that's the sort of the sensitivity issue, isn't it of read the notes and know who you've got in front of you? Yeah. And I think that one of the things as we go through the rest of the day, I think that one of the things in all the things that II talk to patients with lots of different cancers, I think that one of the things that you pick up is that you really have to listen to what people are saying. And just at one point, we wanted a campaign with a sort of hashtag ask one more question. So, you know, so actually you're tired. But what's that tiredness actually mean? Because I was sitting at lunch and the surgery today and about three members of staff came in and said they're tired but actually they're still doing everything. Yeah. So, I think that clarification gives you a bit of context to what patient, what, what patients are experiencing. And I think it, it's the impact on, on your life, isn't it? It's, uh, I can live with this or actually, no, I can't live with this. This is now impacting my quality of life. Whatever that is, that's a sign that actually this is something a bit a bit more. Yeah. Before we can go over with the rest, we can ask Claire more questions at the end. Does anybody have any immediate questions that they want to ask? Claire? I can't say any right? I'm going to try and shout, please shout if this doesn't work. Um You're all good. OK. So I'm just going to run through the NG 12 Guidance. The NG 12 is a suspected cancer guidance, which is good but not perfect. And we'll talk about a bit why it's not, you know. So I think the first one is, is perfectly easy. If you see a woman with a, with ascites of pelvic or abdominal mass, you refer on a suspected cancer pathway. I think that's fairly straightforward, fairly obvious. I think that's what most clinicians would do. And then the next one I think is, is more difficult. Um So carry out tests in primary care, particularly those over over 50 with persistent bloating, early satiety, pelvic or abdominal pain, increased urinary urgency or frequency or new onset ibs and consider tests in women with unexplained weight loss, fatigue or change in bowel habit. I think Claire's story illustrate illustrates that you should be looking out for these things. But actually, I think the um sort of highlighting it is more common in those over 50. But I think you need to be thinking about it in people under 50. The next bit that I have particular um where I actually differ in the way I work from the guidelines. So it says you should do a ca 125 as a first off. Now players said, and then we'll have some figures later on that, that reiterate this, that actually in a lot of people ca 125 isn't raised. Um So if the guideline is only telling you to rate to refer when you've got a ca 125 greater than 35 well, cla would never have been referred and a lot of other patients would have, wouldn't have been because you wouldn't have gone on to do the scan my practice. And I know my colleague who works on Gateway. See with me, Rebecca, her practice is the same that if I've got a patient who I'm concerned about, I will do the ca 125 and the ultrasound simultaneously, I'll request them both at the same time so that I've got the answer to both rather than delaying things. So I think the guidance is helpful, but I think you have to be able to, it is at the end of the day, it's guidance, it's not laws, it's not rules and you have to be able to think outside of it. So I've had the privilege and the, I know I'm very lucky because in my roles I get to talk to an awful lot of patients who've had cancer. Um, I get, and I get to reflect on the stories that they've got and go back and think about what they've said and how you could do things differently. And there are lots of things that I've learned from this. Some of them are fairly common knowledge and some of them I think are just a little bit more niche and things that I've been able to think about. So, as Claire said, and, or all the stats shows early diagnosis makes a difference and I've got a typo in there and I'm really sorry, I hate that's very poor. Um, anyway, but early diagnosis does save lives and it's really important, but it's not easy because any of you who've sat in, in primary care clinics in Gynae clinics, there's a lot of people who've got very similar symptoms, particularly in primary care and G in gyne secondary care, it's a bit easier because you've got better access to investigations. But it it isn't, it isn't easy as easy that everybody comes in with a clear story like Clare's got, is able to articulate it as well. You know, we've got patients who don't speak English as a first language. We've got people who, um, can't read and write who so won't be able to read any information, find it more difficult to express things. So it, you know, there is, it's a difficult thing to do and there are various reasons for that. I think, you know, some cancers are easier to pick up early than others and they have a very, you know, breast cancer. There's a very obvious sign that people are very much aware of and then they will come in. So if patient find patients are aware that lumps are something to be concerned about, they'll ring the surgery, the receptionist recognize the lump is something to be concerned about and they'll probably be put into a clinic. I think that cancers with more vague symptoms such as ovarian cancer are more difficult for the, the symptoms are more difficult to recognize. They're more difficult for patients to recognize and they're more difficult for healthcare professionals to recognize. And we wouldn't be doing a thorough presentation if I didn't say that actually access to primary care is quite difficult. And I think that people that, that doesn't help in these situations, what have I learned? I have definitely learned that history taking is key that you have to ask every question and then some more. So you have to get every piece of the jigsaw that you can possibly get to give you the fullest history that you can, um, to get your diagnosis. And it's things like, you know, knowing somebody's background is helpful but people who have got, who, people who I was thinking the, the, the idea that somebody who comes in for the first time and never comes in is somebody you could be concerned about is true. But actually there's nothing to say that the patient who's been bothering the life out of me every week for five years isn't going to have something serious as well. And so you have to listen to have the symptoms changed. How long have they been going on for? What impact are they having? All of these things are really important and the more information you get and the more context you get on, you know, um, when you say you're tired, what have you stopped doing when I spoke to patients who had lymphoma? Um, and I spoke to AAA few young patients with a lymphoma, they'd stopped doing everything apart from the bare minimum. They were just about getting to work or to college, but they weren't going out with their friends, they'd stop doing sport, they weren't doing anything apart from what they felt they really had to do. And I think that's really important. It's really important for all of us. To give very, very clear safety netting advice. So you might see somebody like Claire who says they've got some pain and you might think actually this has been going on. I've, I've seen them with this before. I think it's the same thing again. So you might think actually I don't need to do anything today. Um, in which case, you have to, you have to be clear what the next a few weeks you expect it to happen. So, um, I spoke to a patient a couple of years ago who had bowel cancer, uh, who had rectal bleeding and was told that she should go back if her symptoms got worse. Now, over the next two years, she was only in her early thirties, her symptoms didn't get worse, but they also didn't get better. Um, and, but because she's been told to go back when they got worse, she didn't go back at all. And by the time she got back, um, she, she had a very advanced bowel cancer and has subsequently died. So you have to be really clear when you're, and it, this, you know, I'm sure a lot of you will be doing general practice jobs and found and A&E jobs exactly what you, what you expect to happen and what you want people to do afterwards. So, similarly with results, you know, I've done a lot of case reviews and you look at results and one of the problems, um, with late diagnosis sometimes is that patients don't understand how much we really want them to go and have these tests done. So they don't go. Um, and, but if you don't tell the patient exactly what, why you want them to have the test and how important they are, you know, if they're working, they've got kids, they've got caring responsibilities, they've got another live, they've got lives to live, they don't go and have these things done. And you also need to let them know how they're going to get the results of tests. So again, there's quite a lot of instances where patients actually go and have tests done and they don't know how to, they're supposed to be getting hold of the results and nobody at the practice quite hangs on to it and gets in touch with them or they just get a, a text saying please come and discuss it. They don't come and nobody's really followed up on that. So I think it's really important that we're very clear about all steps about what's going to happen. Not all patients are as good at doing these things as Clare is. Um And so I think we need to make things easier and I've got another typo, so I'm absolutely mortified now. So I'm very sorry. Um And the other thing is coding can be misleading. Claire said that she was very pleased. Her GP didn't say to her. Um I think this is a bit of IBS. Now, if she'd seen somebody different, um and somebody had previously coded her as having IBS. The next doctor might think. Well, doctor, so, and so's more experienced than I am. They must, they must know she's got IBS, they must be certain, which is why they put the code in. Um, a few years ago when I was talking to the sarcoma, we were doing our Sarcoma module. I spoke to a patient who was told he had a spacious cyst on his thigh. Um by the first doctor through COVID, he then found that it was getting bigger, it was getting inflamed infected. Nobody actually saw it because it was during COVID. But everybody assumed that the first clinician was right and it was a sebaceous cyst and it wasn't, it was a sarcoma. So I think assuming that the first person is right, it can be real problem as well. Um And one of the things that I've noticed people doing in notes is sort of saying, you know, history revisited and you go back and you say, right? OK. I know you've seen three or four different people, but tell me everything that you've been telling them so that you know exactly what people are saying. I think that we need to be sure we need to understand the limitations of investigations. Ca 125 is normal in 20 to 25% of patients with ovarian cancer. So you cannot be reassured by a normal ca 125. The other thing that I've discovered recently, which has made massive difference to, uh and I'm not quite sure how we're going to work this through. Implementing all this is that there's a recent study that shows that women over the age of 50 with a raised ca 125 have a 12% risk of non ovarian cancer. Now, if you think back to the Nice guidance, the nice guidance says, raised ca 125 if the ultrasound is abnormal refer. So it doesn't actually cater for either of these situations. It doesn't cater for the normal ca 125 in the patients with ovarian cancer and it doesn't cater for the raised ca 125 in the patients with non ovarian cancer who are almost certainly going to have a normal ultrasound because most of the other cancers, you know, if you've got a lung cancer, um, or a bowel cancer, it's almost certainly not going to show up on the ultrasound. So we need to, investigations are helpful, but we just need to think about them and deal with the results appropriately. Patients don't fit stereotypes. You know, I said, and when I was looking at, we were going through the guidance that it's very much focused on women over the age of 50. But 15% of ovarian cancer ca cases occur in women under 50. And that's a lot, that's a big percentage and the other thing to remember is transgender patients. Um, it's, it's one of the things that can be quite difficult to, if you've got transgender patients, you may not even, you may not know from name appearance. Um, on their notes that they are transgender and the best thing to do and it can be quite difficult as well to know exactly what if you, even if you do know to know what surgery people have had. I think the only thing you can do in those situations is ask sensitively, most patients will know exactly what they've had. And I think it's important that we consider these patients and ask them. We've in our Gateway C module. We have, they've taken out some of the references we, most of our references to women, but we do say, you know, we have to include anybody who's got ovaries. Um and just bear that in mind, family history is really important. And I've been doing a series of podcasts for Gateway C. And one of the things that we're sort of talking about virtually every week now is you have to ask about family history and you have to ask about, I think the best habit to get into is to basically ask about everything. It's very tempting with somebody with ovarian or with a possibility of ovarian cancer to ask about ovarian cancer only. And that's obviously important, but there are links with um breast cancer and prostate cancer um through BRCA genes. So you need to ask about breast and ovarian and prostate cancer and also a Lynch syndrome. So, you need Lynch syndrome is particularly linked to endometrial and bowel cancers. And so it's important that you ask about all of these things and what I've found because I've been doing this job for a few years now is that there are more and more of these coming out. So I don't know whether we're going to, you know, in two or three years time, we're going to say actually there's a, there's this syndrome which has a link with upper gi cancers or head and neck cancers or various other things. So I think the best habit to get into is just to ask generally about any history of cancer. You don't need to go particularly extent, you know, you want to know about, um, parents, brothers and sisters, maybe grandparents. Um, but not for some of the more common cancers unless they were particularly young. So you want to know about people who've had cancer, young and close relatives who've had cancers. You don't need to spend hours and hours doing it, but you do need to know myth busting. I love a bit of myth busting my kids when they were younger, used to watch Mythbusters. Um, and I just think we need to, I think it's a great thing to look at here. 40% of women think that smear test detects ovarian cancer. I, that's completely blown my mind. I would never have thought that that was something that people would think, which shows how much I know about anything. And so I would never think to explained to a woman when I was doing the smear that I'm only looking for cervical cancer. Um And so I think that that's, you know, so what worries me now, as soon as I think of that is how many other things are people assuming that I just don't know about. And I've got completely off off key with um only one in five women can name bloating as one of the main symptoms of ovarian cancer. Now bloating in women between the ages of 2060 is really common. Um So I think we need to just be raising awareness and then we, I mentioned this one before that half of GPS believe that you can only diagnose this diagnose ovarian cancer in the later stages. Helpful questions. I think it's really important to ask about family history. As I said, I think unintentional weight loss I is and a very useful question. People don't always volunteer it. Um I think that particularly with perversely with ovarian cancer because of bloating, some people actually feel like they've put on a bit of weight. So I think maybe we should for this slide, I should actually put an intentional change in weight. Um I think it's really important to ask, particularly women will normally notice if they, if their dress sizes change, you know, if they're in a different size of jeans, if they're wearing, um, men, older men will often notice that they were in for, we're not talking about men here, but belt size for men. Um, but particularly ask about unintentional weight loss, ask about appetite loss. It's different from weight loss. Um, you know, people who have got cancers often find that they've lost their appetite and don't feel like eating. And that's the reason for the weight loss. If you don't ask again, I don't think people will tell you and then fatigue we touched on, it was one of, um, Claire's symptoms and it's a, it's a common symptom and I think it's really important to contextualize it and understand exactly what people mean when they say they're tired because I suspect, um, you know, that most people say I was sitting at lunch today and the surgery and one of our receptionists and one of our GPS came in and said they were tired, but, you know, they've done a whole day's work and they were one of them. One of the GP is tired is going skiing next week. So she's obviously tired but not, but she's still doing quite a lot. So, examination, I think that again, you can't underestimate the importance of examination. One of the nice criteria is um, abdominal mass, pelvic mass or ascites. You can't diagnose those over the phone you have to see people. I think that, you know, II um through COVID, we did a lot of telephone consultations. I think that there are a lot of things that I'm very happy to do as a telephone consultation. Um But there are some things that you just are better seeing some people about. And I was on a cancer research UK GP call earlier this week and one of my GP colleagues has done some research which has shown that actually cancer patients are disadvantaged by not being seen, face to face. You don't get that feeling of seeing somebody and seeing how much pain they look like they're in or how much weight they've lost or um and, and, and a lot of things are quite difficult to discuss over the phone, particularly sensitive things. So if you don't examine people, you just won't know about these things and therefore you won't refer cos they've got an abdominal mass cos you just won't know about it. So a summary thoughts are always ask one more question, just make sure that you ask every question you can think of to get the context of what's going on. It doesn't actually take that long. Um But you can get a real, you know, with, with sick kids. I always say, what have you had for breakfast? Um Just to get a context as to what's going on. One of my GP colleagues has a policy of three strikes and you're in. So if you see somebody with nonspecific symptoms or things that you're not particularly concerned about um three times and you haven't got a good explanation for them. And I would say that IBS isn't a good explanation because it's a diagnosis of exclusion, then you need to think about investigating them further. The tests that Claire had are easily available for primary care and they're easily available in secondary care. So there's no excuse for not doing them. And I think we should be thinking about doing them. I think I labored this quite a lot before but give really clear and specific safety netting advice and make sure that patients understand exactly what time spell you expect them to get better over and what to do if they don't get better, what to do with investigations, what to do with results of investigations. And just remember that difference between saying come back if you get worse and come back, if you don't get better, could save somebody's life. Don't over rely on investigations. You know, we've looked at the guidance ca 125 doesn't in, um, diagnose all of the ovarian cancers and people with a ac, a 125 could have a normal ultrasound in a different type of cancer. Investigations aren't the answer to everything and then rely on your intuition. You know, that, um, I, as you can probably say, I've been a GP for a long time now there's a lot of research to show that GP gut instinct is as reliable as a lot of the nice guidance for um referring patients in. And the longer you've been a GP, the better your gut instinct is cos you've seen more things and you, you know, the patients and this sort of thing. But if you, if you feel something isn't right. Um One of my colleagues a few years ago said to me, you have to make the decision that make, that means that you're not going to wake in the middle of the night doing things because that's the best thing for you and it's the best thing for your patients. So if you think something, somebody's just not quite right and you're worried about it, do something about it. Um and just rely on your intuition and what you think is the best thing to do, just gonna do a couple of things on Gateway. See before we take. So part of my job is working for Gateway C. You can all access gateway C and there'll be a QR code at the minute for you to do it. We have, it's NHS funded free education for primary care. We have interactive courses, a lot of them based on stories for people like Claire um II do interviews with specialists where I get to ask them the sort of questions that aren't in any of the guidelines you're thinking. Well, what would I do about this? Cos it doesn't quite fit. And then we've got some cancer conversations which are, um, on sort of slightly more topical things a bit shorter. We've got one on proton, um, Pumps. We've got one on cancer and transgender patients. They're only about 10 minutes in length. And we've started doing some podcasts which are really good fun called GPS Taught Cancer. So, if you're bored when you were out somewhere you can listen to myself and Rebecca Lee, I'm talking about that. We've got the target cancer. Um Target ovarian cancer have got a lot of resources that are really useful. I personally find patient resources are really useful for me as well. And if you're not quite sure, um it's, they're useful things have just remembering the things that are on here and sharing them with any family and friends just would be a really useful thing to do. Um Just some more bits of information. There's um the, but the myth bursting stuff is here and there's a myth busting video which I haven't watched, but I really should do. Um And your, your posters that you can put up when you're in GP surgeries, no harm in getting some posters put up because it's really, you know, you might just stimulate one or two people to come in. I think that the um back of the toilet door ones are quite good for um female toilets and GP practices. There are early diagnosis networks and GP networks. Within target ovarian cancer that you can use. Um And so I'm just gonna go through that and come to the end and just go back so that we can, um, see that we've got any questions, right? We have got questions, right. Uh There's a question I think for you Claire about just whether you do have any family history. No, nothing at all. Just me, which didn't really help it. I think the, I don't absolutely know the answer to this one, but I think that the higher the ca 125, the more likely you are to have ovarian cancer. But actually, um because there's that big percentage of patients that don't have a raised ca 125, you just have to be really careful with it. So if you had somebody with a ca and ca 125 is raised in so many other things, um you know, it's raised with endometriosis and lots of other things that you have to be really quite careful about interpreting it. So I think you need, you need the ca 125, you need the ultrasound and then you need to, I think you can refer and ask, I think at that point um Right in the scenarios in which C A 1 to 5 is not raised in a patient who has a, I think it, it, it, I think the research on the C A 125 is, is that particularly I don't know whether it's more the two younger women that I've met with ovarian cancer. I got a colleague as well who, um, had ovarian cancer is similar to U also had a normal C A 125. I don't know whether it's time. I think it's partly down to the type and it's partly down to the very early stage. I don't think it's a very good indicator at very early stage, but I think there are still some C A 12. So some ovarian cancers where the ca 125 isn't raised at all. How many or how many are? Very gi don't know that one. I don't know how many there will be stats. See how UK have got very good stats on that sort of thing as to how many cases you will see a year. Probably. Certainly no more than one or two. It's quite unusual. Um, and 12%. So I don't understand. I don't understand that question. Is it, is James able to, can you, are you asking about the 12% of patients who have a normal, uh, uh raised ca 125, but normal ultrasound and have a different primary? Is that what you're asking about? My? Yes, they are all women without ovarian cancer. Yes. So it's not, it's not women who might have, um, lung Mets from, from a, an ovarian primary. It's women with a different primary from ovarian. Definitely. I don't think, I think there's more, II spoke to one of the researchers about this a couple of days ago and he, they're doing a little bit more work as to what cancers that might be. So, I don't know whether you're all aware, aware of the work that's shown that people with raised platelets have an increased risk of cancer. Um, and those have been shown they're the lego sea cancers. So, lung, um, esophagogastric endomet, you know, lung, endometrial, gastroesophageal and colorectal. Um, but I don't think we've got quite, it's fairly new data that it's a big, but it was a very, very big cohort study. Um And it's, I don't think they've narrowed down to exactly what cancers it might be. So I think it's really, it would be interesting to watch. And I sort of, I remember sitting in a room a few years ago when somebody was giving us all the information on raised platelets and thinking this is gonna transform the way we think about diagnosing some of these cancers. And I felt the same about the ovarian, about the C A 125 because I think it is really significant if you, um I wonder how many women have had a late diagnosis? Cos somebody said, oh, you see a 12 fives raises, but your ultrasound is normal. Um So I think we need to look at that. Does anybody else have any questions? So, we've gone through quite a lot of stuff. Clare. Was there anything you wanted to add, cos anything that particularly you'd want as a takeaway message? I think it's probably not particularly related to this, but it's the message that I harp on about all the time as well as that younger women with cancer or with the consequences of that cancer and just sort of taking that into account a bit. So for me, my biggest issue was that I was suddenly not able to have Children and that I was in the middle of the menopause at the age of 32. And if one more person said to me, well, you just don't fit the mold, do you? I was going to swing for the next person that told me that and I think just an awareness that actually it is really far reaching. I mean, as I say, I was lucky, I was very lucky, but that didn't mean that there sort of weren't consequences of it. And I think just bearing that in mind is really important. There's two ways of looking at it aren't there. You're lucky that it was diagnosed early and you, you know, you're well, but actually you were quite unlucky to get ovarian cancer at 32. You know, I mean, that is not lucky. Um, and so, um, and I suppose, you know, I think most people would think if they got, if they got the diagnosis, think, oh, that's, that's really unlucky. It's very rare in 32 year olds. That's unlucky. So, I think that, you know, it depends. Um, and I think, I think that actually there's, and there are growing numbers, there's, you know, there's a massive increase in the number of people with colorectal cancer. Um, younger people with colorectal cancer. We need to be aware that all of people don't fit, fit in the molds and that, you know, that if you get, we've, it's a whole separate topic, isn't it? But we've done, there's a whole, there's a whole load of things that can impact you later on either from treat, from treatment from all sorts of things as a result of having cancer when you're 32 rather than when you're 72. Um, you know, there's, if people have chemotherapy, they're much more likely to, some of them are more likely to have cardiovascular side effects, neurological side effects, all of these things. And, you know, you've got the hormonal side effects, as you say, of having a hysterectomy at 32. So there's a whole load of stuff that needs to be thought about. That is different for the 32 year old with ovarian cancer versus the 72 year old. Um, so, yeah, I think it's worth it to that last question. Um, they took both because they found that the mass that had aed to my uterus. So there was the risk of it removing that, that it would burst. So they took the whole lot and I think you said that you sort of knew that it might happen but weren't, yeah, it wasn't high on the list of things we were hoping to have to do. Put it that way. Yeah. So that's quite a shock when, particularly when you're feeling rubbish after a general just gone off a cliff as well. It's always a good one. Does anybody have any more questions? I think my takeaway would be that, that the, you did. You need to start with thinking about serious things and excluding them from your mind and thinking about them and lots of people. So you need, you know, you need to make sure that you, you haven't, you don't say to somebody like play out. It's probably a little bit of IBS because you need cos cos it might well be and probably in 95% of more of 30 year olds, it might well be. But you need to have it. You need to ask enough questions to get to reassure yourself or to have covered that possibility if it doesn't get better or if it gets worse or if there's something different about it because if there's something different about it, you, you, so I think it's just, it is. I know and I know it's what you're told all the time as students is, you know, history taking is key. But actually I'm, you know, I'm looking at now, I think I'm just more every year in my appraisal, I think about it even more. I think every year it's just really important because that's where you get the majority of your, of your information. So I don't know whether we've got one more question. Um I think we just got a thank you to Claire for sharing everything. Um And please sign up for some of the resources that are on there. II shared the wrong There isn't actually a QR code on there for gateway C but you can get it on the gateway C website and just join if you want to, if you want to, you know, some the brain tumor module is quite good. If you're doing some revision on that, there's lots of things on there. So have a look and see and let us know if there is anything else you want.