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Hello, everyone and welcome to our medical oncology event within our medical education scheme. Um We have Metal Oncology because we have had such an incredible response from consultants just like Asama who ha who are incredibly gifted in their teaching that we have had so many come along and we have decided to actually have Metal on metal education as our mum. And then we'll have little splinter groups for specialist specialism so that we can have oncology and eventually have other groups. So if you are, if oncology is something that you're really interested in, please follow metal oncology as well as metal education. Um As always, if you have any questions, pop them in the chat and Hello Karar and Ahmed put them in the chat if you have any questions at the end of this event. So in an hour's time, you will get a feedback form in your inbox. We really love you to uh fill that out. I will be passing that feedback on to yours as well. Please fill that out and then your attendance certificate will be on your medal account. So without any further ado I'm going to hand you over Thank you very much. Many thanks. Uh So thanks for the introduction. Uh Good afternoon or perhaps good morning or good evening to everyone I learned about me not long ago actually. So they approached me to share their uh vision about spreading uh um a little bit of a modest and a good level of knowledge to a wide uh audience. And I uh I have a genuine interest in teaching and sharing the knowledge, the experience. So I said I would uh very much love to help. So thanks for the invitation. Again, I uh have uh made slides for you because I learned the audience are ranging from medical students to early career clinicians to perhaps even uh senior level clinicians. So I hope the slides, you will find them informative and um shedding the light on a, on a rather important uh topic in women's health and uh to, to trouble you your time over the next 35 40 minutes, perhaps to have some information about gynecological malignancies. And I will leave some time at the end probably to try and answer as many questions as possible. A very brief background about myself. I am Osama AI, I'm a consultant gynecologist. I am um based in London. I work in uh two healthcare organizations within Central London, uh which is guys and ST Thomas and SC A healthcare. I have to say they are uh very proud uh organizations, they endeavor to strive and to deliver the best uh using um very strict evidence based practice, advanced diagnostic modalities, which I believe it may not applicable to all the health care settings. So therefore, these lies will try and probably make it as a happy medium. Um to see how can you improve your sixth sense? How can you a sense? Whether could there be a gynecological malignancy here that I could probably pick up early and manage effectively like all forms of cancer. Uh The the the winning the battle is by early detection. So I know probably cancer care has reached advanced in terms of chemotherapy, radiotherapy or even ultra ladic radical surgery. But this will come on the with the expenses of exhausting the patient physically financially, uh emotionally as well. Um There will be challenged with the high rate of recurrence on certain occasions. Uh You, you would probably unlikely to achieve a cure and uh let alone the financial implications on the health organization as well. So therefore, I hope we will be able to achieve a stage that early detection is available to, to everyone. It is uh um an access to to every clinician because if we are able to detect it early, then there is a very, very good chance we could win it to a cure level. So I'll start my slides on a very brief description about myself. I am um I've joined guys and Thomas since 2016, I have joined it within the call it assisted Conception unit. Uh and then ranging to the early pregnancy and emergency gynecology until I was appointed permanent member of staff uh within this building here between Guys Cancer Center and between the shot um uh within the Surgical oncology uh directorate. And this is simply because I have been a little bit fortunate to learn and um pretty much master advanced pelvic gynecological ultrasound. And I have an analogy about this ultrasound for the gynecologist, I call it as a stethoscope for a cardiologist. So um uh in modern gynecology, ultrasound should be available in every clinic in every uh um woman's health facility and should be done ideally by a gynecologist because they will be able to tell and connect the history, the clinical examination with the ultrasound findings. And this is for the benefit of the patient as well because sometimes ultrasound can be reported by a third party sonographer. But uh sharing uh some findings on the ultrasound report that may be relevant to the clinical context and may not be relevant. So therefore, um by uh by picking up lots of sorts of, of pathologies that of not clinically significance, this will add unnecessary anxiety to the patient and will be committed to treat it as well while at least if you are a clinician and pick up some abnormality, like for example, very small teeny tiny fibroid that has no clinical significance, at least you can tell the patient this is just for the finding. Just for the report. I tell my patient, please ignore it, pretend it's not there. So uh that's why I have probably applied this uh ultrasound skills in a, in a wide variety of women's health because it gave me a broader spectrum of um of, of um between fertility, between gyne uh benign gynecology and now into the cancer work. And I lead now on the cancer diagnostics clinic at GE, we also run a, a very uh efficient um and successful uh complex ovarian cyst clinic that we receive referrals for it. So if a GP suspected or if a clinician suspected uh a mass that is not probably straightforward, we call it complex simple. We ask us to provide a second opinion and then after that, we, we, we manage the, the, the uh the the case um in a, in a certain format of certain protocols. I also um other parts of the cancer diagnostics within uh the Colposcopy. And I have a genuine interest in, in providing value based healthcare which we will touch on it uh at a later on in the, in the uh in the slides in the presentation. So overall, what we are going to talk about, what are the current trends in the in surgical gynecology? What are the global j challenges for cancer services? How to talk about value based healthcare and how to spot the red flags and how can we manage and leverage on modern on the spot diagnostic imaging. And we will also touch briefly if hopefully some of you, maybe all of you are aware of the iota and I ea classifications for endometrial and ovarian cancers. How can we apply A I in cancer diagnostics? And what will the future hold for us? And hopefully, we will conclude with some questions and, and uh and answers now. So my father is a gynecologist, by the way, we are originally from Iraq. Um I do remember when I was in school, when I was in, in high school, uh every time he comes from clinic and tells, tells my mother to speak about difficult hysterectomy, difficult operation, difficult Cesarean section. So what I gather now connecting the dots down the line that hysterectomy in the past used to be pretty much the one and only method of managing benign gynecological conditions, ie abnormal uterine bleeding, um uh irregular period. Uh It, it used to be a, a very low index of offering it. But now over the last probably 30 years when advances in medical management of abnormal bleeding, in terms of wide variety of hormonal contraception intra con uh devices, uh fibroid embolization. So the the odds of, of having a hysterectomy has markedly decreased for offering it. And uh on this graph, uh which is a population study, this is actually from the wh o about the the odds of hysterectomy over the last um 30 years and you can see the downward trending for a, for a variety of, of, uh, of sorry. There are no slides on the screen. Oh, is it because we, we, we shared the slides, I believe. No. Is it? So, if you click on present now, is it not sharing? What's it doing? I'm seeing my slides actually, um, stop presenting and now present now. Ok. There, now we've got them. I don't know what happened there. Ah, please, can you, it was all right. Until now. Can can we double check if the slides are visible if someone can say yes or no, I can see them, you can see them, see them on the, what the delegates can see. OK. Fantastic. OK. Yes, let's go ahead. Lovely. So I'm sorry if you have missed. Uh I can, I can run uh briefly very quickly. I uh we talked about myself. I don't want to bore you uh with that, but this is the, the overall, what are we going to discuss in these slides? And uh uh pretty much we're going to start from there. I was, I was, I was explaining that Hysterectomy for benign disease has decreased and, and uh and the, and, and the national international figures, by the way, for a wide variety of uh of reasons, simply because the advancement in the medical management of irregular vaginal bleeding. Now, this is important, this is useful uh because we are saving an operation. Unfortunately, now we are having the other tail end of the cycle. So the odds of we call it um simultaneous comorbidities by keeping uh the pelvic organs for especially if they are troubled with the with the pathology for a longer time, then the risks of cancer will increase with that. And this is simply told the commu com uh commutative burden of the disease. We are indeed decreasing the level of the hysterectomy. But at the same time, other gynecological pathologies will be on the rise and it is particularly endometrial cancer. So this is the projected rate to increase and a very alarming uh rate over the next probably uh 10 to 15 years. Simply because fair enough hysterectomy has been an effective method because this, this is literally eradicate the odds of attracting cancer. Uh We've managed it effectively and successfully and satisfactorily to most of the women by avoiding a uh uh a a major operation. But now at the tail end of the cycle, it's coming other comorbidities with this approach. Uh So therefore, the the idea comes uh to, to be vigilant and to be uh knowledgeable and skillful in and picking up uh ear early stage uh genital tract malignancy. I hope the message is clear with that. Um um um It is, it is uh we are going to, we can discuss it further on in the, in the discussions. So, because initially there was some uh animations in these slides. So that's why these slides will come all in one go. But I will tell you about this previous picture here. This is a picture has uh probably at the end of my training has been uh published which we call the GF report. Get it right. First time. Uh This has been established by probably a lot of stakeholders here in the National Health Service. They are realizing patients are not seeing the right clinician, not on the right pathway and not benefiting from the right service. So therefore, quite often, this is a financially exhausting exercise no matter what much you you refer. For example, if the lady with incontinence, you refer her to a uh a clinician specializing in uh probably a fibroid disease. At least I'm explaining from the UK perspective, we have become so much super specialized within women's health that although general gynecologist is still available, uh but they are at a very much primary care just above the level of the GP to be able to manage. If there is any specialized complex, your gynecology, fibroid malignancy, they have to be sent to the super specialist. So the NHS was crippled with this patient so much lingering in the cycle, not seeing the right patient, not see, sorry, not seeing the right clinician and not on the right pathway. So they have published a report, we call the GE report that and we although it was primarily focused on obstetrics. So, but we have managed to speak to the Royal College of, of uh Obstetrics and Gynecology at the time with quite a few other colleagues and we tried to leverage on that report and applied it to gynecology. How can we apply uh apply value based healthcare in gynecology? And one of these recommendations is try to improve the line of communication, which is again a very weakest link. By the way here in the UK between primary care or and between the secondary specialists in the hospitals. If in other countries or in other settings, this could apply to between clinician to clinician referral. Just to please ensure if this is a problem, try to find the most suitable person for that problem because this will save the time to the patient, to her family and to yourself. So, uh therefore, we developed a lot of outreach programs to the GPS in the area to try. And we, we have a specialized expedited pathway. We call it the cancer pathway. Unfortunately, it's one of the anomalies is being very much exploited by uh probably patients bombarding the GPS and, and causing so much pressure on them. So the GP out of desperation, they activate this pathway. And because I run this pathway myself on the N HSI, have to say, probably almost 40 sadly, to almost 50% of the referrals we receive, they triggered the cancer pathway, but they are not actually a cancer. Um uh the suspected patients uh probably name it uh Polycystic Ovary and irregular bleeding, uh a little bit of abnormal fibroid. And we, when we inquire that there is a weakest link in the communication. And that's why we try to establish some outreach programs to establish um a proper pathway for these referrals. And this has huge financial implications to all parties involved. So that's what we mean about pro providing a value basis, how much money you spend and what is the value for you you're coming back from, from it. And therefore we acted as the in uh intermediary and ideally by providing a prompt diagnosis and support or excluded promptly and reassure. So quite often patients when they come to the cancer clinic, we endeavor to establish one question. We, we tell the patient, we are here that to answer this question, is there a cancer and I'm able to, to diagnose it and support you onward in the journey or if there is no cancer and I can assure you. But unfortunately, that doesn't mean the solution to the problem. So if there are multi froid uterus or if there is um a lot of um um hormonal imbalance leading to abnormal bleeding, suspected to be cancerous, particularly after age 4045. Um we do the diagnostics, there is no cancer, but we tell the patient this needs to be on another pathway with another team to be managed it more effectively. So if you're able to pick up this when you, whenever you have a uh an interest, special interest with, with gynecological malignancies. The main question is, am I able to diagnose it promptly? What do I need to do it or how can I re exclude it effectively and reassuringly and get the patients to move on if she needs to uh get the problem sorted with other team or with other disciplines. Now. So let's go, let's talk about uh cancer, the the diagnostics here. So what I do generally, I tell the patients, tell my colleagues the rep productive system of the woman is a very, very sophisticated sy system. We have very shallow compared to, to, to you guys. So therefore, this system, a lot of things have to work together in terms of the hormonal cascade, in terms of the anatomy, in terms of the reproductive function, the menstrual health, a lot of factors. So therefore, we, I do call it the dashboard. And in order to ensure the best indication that to tell you that the dashboard, the system is working well and operational without any problem is when you have a healthy, uneventful menstrual cycle. So this is the best indication, very, very sensitive and very simple approach. If you see the woman having uh um um any gynecological problem, if you establish this s uh question, generally ask her, what is your baseline? What is your default of the menstrual cycle? Is, are you if you are used to heavy period, then this is probably normal if you used to have a normal period, that's become heavy. No, this, this, this is worth investigating and elaborating on it. Um More. So therefore, simply because menstrual irregularity is common and it is uh most of the times not concerning, particularly when it, when it happens in the teens, this is most likely functional. So I wouldn't worry too much or, or, or scare the patient too much. You need to be vigilant when it come probably from age 45 plus. Uh because the peak incidence for diagnosing gyneco gynecological malignancies generally tend from age 45 and peaking almost in the seventies. So these are the areas if you have irregular bleeding for a woman in this age group, that's to be probably put a little bit of a cancer hat on and try to see could there be a cancer that I am unable to diagnose or probably miss. Now, um again, I realize probably there are some medical students when I learned it as well. I found these terms quite confusing to be honest. So um Aoria polymnia and luckily now they have, they are all being um pretty much scrapped and there's a new terminology more simplified. Uh Although by the textbook, unfortunately, because these slides are um that imported in a PDF version, there are multiple slides in one in one section, but you can tell you from the figure here, you can characterize the normality of the menstrual period by frequency by the duration and by the volume, but practically who would have the o the opportunity or the time perhaps to quantify it and be by textbook. And therefore, personally, I don't think this is practical, to be honest, this is only for theoretical and for exam purposes. Luckily, the fal classification has come. Uh So before the fetal classification, we talk about it. So um this is just to tell you that how irregular bleeding is costly to all the healthcare systems. This is probably uh a little bit of uh an old uh paper, but it's just summarized in terms of the cost for GP visits between hysterectomy, between medication therapy and totaling for woman visiting the healthcare provider in the United States is nearly 1 billion and that was almost uh 15 years ago. Imagine the time the the costs now. So therefore, the sca the scale of the problem, particularly with irregular bleeding, we are going to focus on it a little bit more today simply because again, for, for one reason is the because of the audience to make it a little bit more uh closer to the reality. And plus I do believe it's a very, very sensitive uh marker to telling you particularly in the high risk age group that we explained. If the woman tell you there is a, there is a problem with my period, then this is a red flag for probably gynecological magnate. So therefore, just, I hope you don't mind to elaborate on this particular matter a little bit further. So in general, they have two fold increase of seeing the GP attending A&E or even needing a surgical procedure. It consumed at least 10% of women in their reproductive age per consulting for the GP in England and Wales. There are an access of half a million women. They visit uh the GP for abnormal period in the year. And uh L leading to increasingly now, like we we discussed, we are reversing the cycle again. The hysterectomy rate is on the rise because of that. Now, back to the abnormal bleeding. Remember that we agreed, hopefully, I convince you to forget about amenorrhea, polymnia and all this uh confusing terms, the fecal classification has come for management of irregular bleeding. They are simply call it a UB abnormal uterine bleed or polymnia, amoria, uh menorrhagia, uh Oligoria. This is all going to be called and it is being called now as we speak. Uh A UB and this has been characterized into structural causes or nonstructural causes. And the structural this ano uh acronym is Palm Coin, whether there is a polyp adenomyosis, fibroid malignancy or hyperplasia. And then the extra structural one, whether it's called co any problem with coagulation or endometrial ovulation uh or uh ovulatory or probably iatrogenic that's often as well uh getting picked up. And in this slide, we explain it here. This is can be a precancerous condition. Polycystic Ovary, even in young girl and young, young girls. Unfortunately, we had a diagnosis of ovarian cancer in a woman who was 28 two weeks ago. But this doesn't come haphazard this come within a clinical context. Firstly, she's morbidly obese. Secondly, she's P CS. Thirdly, she hasn't had a period for four years. So therefore apply this in the context. Yes, PCO S is a probably a precancerous condition. Uh I wouldn't say it. So in a, in a, in, in an alarming way to, to, to scare and panic the young girls, I'll explain it that this is an altered physiology. The idea of the safe practice is to have to be managed effectively because if it is not, especially if it is not compensated by achieving a healthy body weight, then this could be precancerous and we, and we have evidence of that. So therefore, uh polyps can be precancerous malignancy, whether ovulatory dysfunction with PCO. Uh if it is intrauterine devices like the copper coil um uh coagulopathy, all these acronym has been, has been explained in this slide. And most recently, when they said at the end letter, when they said not yet specified, for example, Cesarean scar defects. And again, this is a matter of, of uh special interest to me because that was the matter of my phd thesis. In fact, they, we did find from lots of studies, we did that incompletely healed Cesarean scar and we've published about that as well. That could lead to a reservoir of unhealthy circulating blood in here. This endometrium contracts in the second half of the cycle to push the blood outside. Now, if this blood does not being pushed properly, it will remain stagnant here and often translates into probably irregular period. So there are certain criteria for that to see if the deficiency is uh mild or moderate or severe. Fortunately, my paper here is just behind what it is not showing. Uh we, we we we put terms and conditions all available on public. By the way, the terms and conditions help to characterize deficient scar and what are their clinical implications? And um uh if if it is of certain deficiency, then it is probably amenable to surgical correction. So this is one of the causes for abnormal bleeding, but please please provide it within clinical context. We agree that abnormal bleeding probably an alarming feature but not to be alarmed yourself. Any, any irregular bleeding could be a cancer. No. So just have a helicopter view, see where else it could be. And the this the clinical story will lead you itself. The the the alarming features will will lead you will be able to pick it up for sure if you apply a systematic approach. So let me help you with a systematic approach by obtaining a very simple basic history. Try to characterize it in your head. Is this is this lady premenopausal or postmenopausal. The postmenopausal, this is auto automatically a trigger sign that's automatically your mind is tunneled. This I am here to exclude cancer until proven otherwise. But if it is premenopausal, no, probably it could be extra cancerous regions and therefore try to simplify it. That's how I simplified, explain it to my patient. Could be structural or organic, could be hormonal, which is the most common cause or it could be infectious. And again, only this is applicable to women who are multiple sexual partners, unstable relationship, frequent travelers or there is a history of sti so most of the time I tell them this is pretty much the main causes for that. Now, risk factors for endometrial hyperplasia and cancer. To be honest in my, in my set up in my uh in our setup of guys and Syto, we dropped this into 40 but I'll tell you the reason cause we do serve uh a population that are known to have high risk of endometrial cancer, our catchment area. Uh it is known to have a huge um um wo women who, who are known to have fibroid uterus, make the diagnosis a little bit difficult. And therefore you rely on advanced imaging because ultrasound will be limited. So and we, we do have high high rates of, of cancers, but because we are a little bit biased because we are a cancer center. So we only see the high risk patients. So for other settings. It all depends where your setting is. We could probably stick to this because it is uh uh evidence based above age 45 no previous pregnancy history of PCO S, we mentioned that history of very long time, not only one or or two episodes, very long time of pro uh prolonged unopposed, high dose estrogen therapy. This is a risk factor because sometimes you, you know the the people, unfortunately, the media not often constructive and I have to say H RT has attracted a lot of unfair media on it recently. At least we see it here in the UK. In my opinion, is the least factor to be blamed for endometrial cancer. And it is often often overlooked. H RT can improve quality and wellness of women has got a lot of huge benefits and on a theoretical uncalculated endometrial cancer risk, I don't think this is um um founded uh properly with the adequate counseling, with the proper monitoring and provided patient compliance as well. By that H RT has way more benefits than, than the risks. So BM I diabetes hypertension family history. These are all those factors that could help you to, to, to tunnel yourself into a cancer diagnostic uh work. So there are also a couple of uh important information that is actually the pathway from our uh G GGP colleagues when they recommended if women presenting with au apply the fecal classification and if it is reassuring initial picture start some iron supplements, start some hormonal contraception and then after that refer to secondary care. Although this seems to be lovely doubly, but they have put as a backup in case one to refer woman without excluding this pathway without initiating any treatment. If uh the pressure symptoms, if you feel an abdominal mass, if you picked up an ultrasound, that has shown a large fibroid if there is a polyp actually. So there's no, there's no point of starting iron tablets or hormonal tablets. If you have picked up an organic, that's why if you get back to the to the slides between organic or ho or, or, or functional uh causes if you pick up a pathology, you have to treat it because there could be a combination of both, but it doesn't make sense to start hormonal treatment and you have a pathology that is not treated or at least you agree that it is not contributing. For example, if you pick up a polyp, this polyp has to be removed before initiating. Uh For example, hormonal contraception without any organic pathology. If you noticed that after 3 to 6 months, and there is no response. And I have to say six months is generous, especially in the high risk group. I would say three months try. There is no response. We have to escalate the uh the investigations or most importantly, patient wishes as well. Here, this is often overlooked and I'm very glad to see this in this recommendation. Because in the old days, the patients have either A or B or B or C. And now the approach is, is, is has become different. I say there are no options or there are all options. You guide me, you tell me how would you like this to be managed? Uh The most importantly, sometimes patient, they say they come and tell you my period is problematic. I just need to be assured if there is nothing wrong. I'm happy to put up with it. Another approach they said no, they are problematic and they are affecting my quality of life. Even when there is no cancer, I need it to be fixed. So you could at least facilitate an onward referral for her. For example, refer her back to the GP start hormonal treatment. The GP calling cancer has been excluded. We thank you very much for the referral. However, there is a problem, needs uh needs addressing patient wishes to have this type of treatment and I think she should be supportive. No. Um I have to say this comes on the expense of requiring a state of the art clinical facilities which we are a little bit on the fortunate side to have them uh in order to provide a one-stop service for, for gynecology because we real realize the psychological morbidity for a woman coming to your clinic and cancer in her head. This will probably affect her wellbeing. Psychology, her family and her career, her work. So therefore, the the shorter the time you keep it to answer the question, the better for her, better for her family and better for you as well to give you satisfaction. So in order to shorten the time you need to be supported by some form of on the spot, good quality clinical diagnostics. And we are fortunate uh on that. So we have an ultrasound scan that we can perform ourselves. We have a few suspecting a polyp, we can perform office hysteroscopy straight away and be able to remove whatever pathology or biopsy and to, to shorten the time to obtain the results. If there is any uh a problem with the cervix, we can apply the Colposcopy all in one couch, the woman stays in one couch without any changing. Go there, come here, do this and do that all in one set up which even in the UK, by the way, it is not available in the, in, in all the, the the healthcare sy systems. But we are a little bit on the lucky side that we are able to provide such an answer quickly. Now, uh we touched briefly on uh I know we, we, we said we will agree on on having the, the, the abnormal bleeding um as, as the pa noon uh description for um genital tract cancer. I'll touch very briefly on the Aita classification. This is a very nice, I called my Bible, especially for physician who scan or have interest in scanning. They developed a certain criteria to characterize in the material pathology based on not only in the material thickness, it's based on the regularity based on the homogenicity based on the uh uh Doppler score and based on the um um endometrial myometrial junction, whether it's diffused or disrupted. So it's a very, very good description paper. It will help you to tell whether is there a uh a probably ultrasound suspicion of cancer? And the same applies with the IOTA group as well, which I have been also a little bit unlucky to work directly with them and publish with them. And simply because the ovarian tumor has attracted a lot of interest, but I can simplify, simplify it for you. It's between normal benign borderline or cancer. Luckily, cancer of the ovaries remain uncommon. But the challenge with it 70% diagnosed at stage three. Unfortunately, there is no screening yet has been established for cancer. Ovarian cancer. Very, very sadly. So I'm hopeful we will be able to win to win this because endometrial cancer is kind of less harmful. Let's put it this way than ovarian cancer. Ovarian cancer often picked up at a late stage and it's a very tough bitter battle to win. Sure. Thank you very much. I hope that is um informative and at least will allow us a few minutes more to have some discussions and, and answering some questions now is age related or is so, is there anything? Yeah. No, I think we'll just see. Uh So if you wish to put some questions in the chat, that would be great. Um So yes, you saw the two questions here from Rinko and Sara. Uh What are the reasons behind a deficient cesarean scar, infection, postpartum? And then SAR is one as well? Roughly. OK. So we'll answer uh Rinko question. Look, that's a very good question. If you, if you stick back to the principles of simple wound healing, wound heal, satisfactorily provided, there is adequate success factors for that is, is the cut is clean, is there is infected or not? Uh and how it was sutured as well. So in terms of the Cesarean scar, the uterine niche, we found that the the niche becomes more evidently deficient if for example, the Cesarean done as an emergency because often the cervix has been fully faced, fully dilated often in the middle of the night, often more probably uh maybe less senior people are available on the ground. Uh I have been a victim for that myself, a junior registrar that is I wanted to deliver as soon as possible to get the baby a good outcome. So therefore, probably things make on a rush on less meticulous and this is often related to probably a little bit poor healing factors and there remain to be patient factors for that patients who are on high BM I diabetic develop postpartum sepsis infection. This is often compromised the healing simply because the odds of ischemia increases and therefore deficient scar develop more commonly in this age group. So that's um a good question. In fact, thank you for that. And I hope that answers this for you. Uh Sarah Mekhi is, is age related to HPV vaccine to prevent very good question again. So look, it has been uh it has been a lot of uh interest in HPV vaccine. I uh it has not been established fully in the NHS because you, you know, probably in the NHS or government set up, they have to be uh huge financial implications for it. But on the private sector, no harm has been proven and a benefit might be proven even if the woman has got HPV. Contrary to what's often stated in the past, uh which we do it here uh in young girls like we call it HPV, naive, you vaccinate them at a, at a very young age. In order to cause induced primary prevention. There is some evidence. The novel trial has just been published and it's confirming that particularly for women who had treatment who had cervical loop excision and with a proven test of cure HPV negative vaccine will, will, will be, will be of added benefit. At least it attenuates the current titer of the virus HPV and make it weakened and even if it is positive, its oncogenicity. Will be weakened as well. So I am, I am pro HPV vaccine in fact, and age related in the UK. We do it here in, in young girls before starting school as part of the national scree uh vaccination program. But II vouched for a woman of any age group, but I do tell them, unfortunately, it's not available on the chest. It will be done privately. So sorry, just to clarify that one, only because I've had kids go through it and they've had that vaccine and I've always thought fantastic. So, so an adult, obviously they were at school so an adult can have the HPV vaccination as well if they wanted to, but they have to pay for it. They have to go privately. Is that right? True. But for, for teenage girls it's on part of their childhood vaccinations kind of thing. Yeah. Ok. Thank you. Does COVID lung COVID predisposed to gynecological cancer. God hear not from you, please. I hope not. I don't know the answer to this and I hope it has not been uh um and it, I don't, I don't wish to, to happen to anyone. So, no, I don't know, to be honest and I hope not. Right. Um Zakari, uh, does herpes related to Vulva survivor cancer? Absolutely. Yes. Look, any herpes simplex, herpe HPV, whenever there is herpes simplex virus, believe to a certain, to a, to a certain extent that could be correlated HPV virus. So, Therefore, in, in the UK, we invite girls to cervical screening every three years and this is our safety margin. They have to encourage with a lot of colon recall system. But if uh a lot of women, they have genital herpes, we often ask, are you up to date with your cervical smear? When was your last cervical smear? Was it normal? Have you ever had abnormal smear? Have you ever had cervical treatment? So that's the, the, the the way we approach it because we assume that they shared a a close clinical correlation. But um when there is no reliable history of cervical screening for us, at least, then this will raise an an index of suspicion. It does an unremarkable abdomen, pelvic ct scan done for gi indication preclude the need for further investigations by a mono transvaginal ultrasound. Uh-huh, very, to be honest, that's a very we have gastroenterology colleagues and we often share patients from us. We call it the egg from the chicken or chicken from the egg blotting. Take it for example, abdominal blotting. We often say it has to be cleared by gynecologist before gastro and gastro, they say no has to be seen by gastroenterologist first before. So it a apply the common sense, apply general approach, uh unremarkable abdominal pelvic ct scan done. Um If there are no uh no uh no gynecological symptoms, then why would you need to investigate? We have to be in, in good faith and be a little bit pragmatic and uh and, and, and practical but is the woman having uh particular gynecological problems then probably ultrasound is more appropriate than CT scan. So the answer is a apply the clinical context here because the the answers could be yes in the absence of symptoms and the answer could be no if there are symptoms. Carla Thompson is C A 125. Definitely a rule out. No, C A 125 is a nonspecific inflammatory marker. It can be raised to a wide variety of conditions, primarily fibroids, endometriosis and could be ovarian cancer. So therefore applied within clinical context, please. Normal C A 125 does not exclude cancer. High C A 125 does not confirm cancer. Please give a criteria for complex ovarian cysts that we, we worry about and repair. This is very good question. So ka look cyst again, apply clinical context. Age is important. Are we talking about premenopausal? The cyst could be um uh simple if it is unilocular, it's all explained in the, in the iota uh paper that I shared unilocular, no solid component, uh no papillary projections. Um apply the simple rules, apply the B criteria and the M criteria. There are B criteria for benign and M criteria for malignant and you won't get lost, trust me on this. So it, it needs a little bit of training and, and more pattern recognition to see it. For example, dermoid endometriomas, tubo, ovarian abscess in young age, um, uh simple cyst adenoma, mucinous cyst aema. There's a lot of benign tumors, benign ovarian cysts, but they are not cancerous, but each one of them has got certain ultrasound criteria. So, um, I don't, I don't ca ca call it uh complex, to be honest. II would rather call it in a little bit more. This is a dermoid, this is an endometrioma. This is borderline tumor. This is papillary, ovarian serous carcinoma. So we, we, we, we don't follow a simple or complex. Er, I'm afraid just a little bit the, the paper will explain it very, very nicely for you. Yeah. Were there um were there any studies regarding the preservation of ovaries in early stage in the Merial cancer? Rather than 90? Absolutely. Yes. For we do a lot of uh uh fertility Preser preserving, preserving um um surgery. But this is particularly important. It depends on the grade and the stage of the cancer. If it is grade one, if it is stage one A uh has not exceeded to the endometrium, we offer hysterectomy and with ovarian conservation. In fact, we can sometimes give them very high dose progesterone uh in terms Mirena coil and depo Provera at the same time and we allow sequential endometrial biopsy. This is only applicable to grade one uh and endometrioid as well. What type of cancer? It is therefore, it's got to be within a multidisciplinary team. But let me give you the example here, grade one endometrioid stage one a uh wishes to preserve fertility. We give them high dose progesterone and depo Provera and do sequential biopsies every three months. And then if we manage to achieve reversal, then we give them a year, take the coil out to get pregnant and then after that, we monitor again. Frequence, then offer hysterectomy. But if to answer your question to offer it without removing the surgery, then yes, it is possible. Recurrent ovarian cyst for ovarian cancer. No, not particularly. Please apply the, the, the, the risks, risks for ovarian cancer is again completely clinical context. There is a family history, no parity, no history of previous contraceptive pill. Um, a previous cyst that was deemed borderline, a previous cyst that was deemed, um, uh, uh, uh, requiring extensive surgery. A previous ovarian cancer in one ovary that was removed and the other ovary was not. So, it all depends. Not every cyst is, is a risk factor for ovarian cancer. Why is ovarian cancer easily missed? Uh, I wouldn't say easily missed, but because there is no screening program, we, we women, they don't go to have ovarian, uh, uh, to have a pelvic scan every two weeks to try to, to pick it up. It's unfortunately very rapid progressing and no matter if you do ac 125, even every week, you still can miss it. And it's not practical. There is no screening program. That's why it is the battle with this while in the, in, in terms of the cancer of the uterus, because there is it, it lead to problems, it can produce symptoms. That's why ovarian cancer often produce nonspecific symptoms. It needs a little bit of a very low index of suspicion within a clinical context. While endometrial cancer always manifest in the form of abnormal bleeding. That's why I chose to elaborate a little bit more on it today cause abnormal bleeding within the high risk group. It can, it can, you can pick it up easily and, and uh uh earlier as well. Ultrasound, watch the space for that A I ultrasound I wanted to discuss on it. Uh but at the time, it didn't allow, it is a work in progress. It's a huge element of, of, of investment research interest. So I am optimistic about it. What would you advise primary care clinician to look to an increased pickup for cancer of the ovary? Again, to be honest, uh again, this is the same question. There's no effective screening. I'll spread the knowledge, advise the woman to be more vigilant and uh to report any unusual particular pain or blotting symptoms. And I would never say no if the woman is worried and wanting to have periodic scans, although sometimes on the NHS is not available. But if they're able to avoid uh uh to, to afford it privately, I'll say absolutely go for it. It is, it is not a bad idea. Not guarantee it will pick it up, but at least it will help you to, to um to feel le le less worried about it. Right. That's perfect. You've answered all those questions. So we do get quite a lot of questions right enough. Um That is brilliant. Thank you very much. It's, it's really, and I'm sure the delegates will also agree that was really informative, really good. It's, you know, you, you often worry about cancer is one of those things, isn't it that you just worry about any, any human worries about it? Um Yeah, so, I mean, if it's one of those ones that you can't see or doesn't have obvious symptoms, then you do have to rely on different factors and, you know, circumstances and all that kind of thing. So that was absolutely brilliant. Um Thank you very, very much so to our delegates. Just so, you know, it'll be on the hour, which is when we started, that's when the feedback form will be in your inbox. Um Please complete it. Um And we can then uh pass on the feedback to s and who knows, maybe he'll say, you know what I could do another one of these talks. These were very good. So if there's anything more you want around this topic, do pop it in. Uh we'd love to know what you wish to learn so that we can help you. Um and that's it. Once you fill out a feedback form, your tenant certificate will be on your medal account and you can download it. All right. So everyone is saying, thank you, everyone is very happy. So as and I will say goodbye to everyone. So thank you all very much for attending. Thank you. Thank you very much. Indeed. And uh we, we had with sue this communication to run it quite a few months ago actually. But uh back and forth between synchronizing the diaries. I'm glad that we agreed the time now. Thank you. We'll have another one might be. Thank you, everyone.