 Welcome to the ANU. I'm Robin Lucas. I'm the head of the National Centre for Epidemiology and Population Health, where the ACT Asbestos Health Study was undertaken. I'd like to start tonight by acknowledging the traditional owners of the land that we're meeting on today and pay my respects to the elders past and present. So what we're going to run through tonight is the main investigators for the ACT Asbestos Health Study are going to tell you about the results and then we'll have about 15 minutes at the end for you to ask any questions you like of those people. So we're going to start straight off with Associate Professor Martin Kirk who's going to tell us about the study. Thanks Robin and thanks everyone for coming. It's really fantastic to see so many people here. So tonight I'm going to give a presentation just the first part of how the study came about and some of the early findings. Then Rosemary Corder will speak about the results of the recent study findings that have been released and then finally we'll have Bruce Armstrong reflecting on some of the findings of the study. So first things first I'd really like to thank particularly residents of affected homes. Over the last couple of years we've had to engage with residents not only through the study but just in day to day life and it's been a very humbling and important part of the process for us as epidemiologists and working on this study. Also like to thank the ACT Asbestos Health Study Steering Committee, the ACT Asbestos Response Task Force, ACT Health and the State and Territory Cancer Registries who facilitated access to data around Australia and of course the study team who were listed on the initial slide. So everyone will be familiar about Asbestos and the health effects. Really the key disease that we're thinking about with Asbestos is mesothelioma, which is a cancer of the lining of the lung or the stomach. The key thing about mesothelioma is that asbestos is pretty much the only known cause of that cancer. 80% of people with mesothelioma have usually had occupational exposure with the remaining unknown cause. It usually develops 10 to 50 years after the initial exposure so it's a very long time period. The average life expectancy from diagnosis to death is less than nine months so it's a very short cancer prognosis. In terms of the different types of diseases, not only mesothelioma, there are other diseases including lung, laryngeal and ovarian cancer which are caused by Asbestos and possibly pharyngeal, stomach and colorectal cancers which have been associated in some studies but not all. High levels of Asbestos exposure can also result in Asbestosis and pleural plaques of the lungs. So obviously everyone here is familiar with the Looseville Asbestos insulation in the ACT or the company was commonly known as Mr Fluffy and this is one of their ads. In terms of the timeline which people will be familiar with, in 1989 to 1993 the Commonwealth and the ACT governments removed visible and accessible Asbestos from affected properties conducting a search of 60,000 homes. In 2005 the ACT government wrote to owners advising to take care during renovations and in 2014 there was discovery of a house that had been unremediated and they did an assessment and found fibres in living areas in approximately 60% of homes. And then in October 2014 the ACT government, Asbestos Response Task Force, initiated a buyback and demolition program which people no doubt familiar with in this room. So in terms of the governance of the study we were approached by ACT health in 2015 to take on this work. The study team was independent of government and it was overseen by a steering committee chaired by the ACT Chief Health Officer Dr Paul Kelly with members from the study team ACT Health, ACT Asbestos Response Task Force and New South Wales Health. In terms of the funding ACT government provided funding for the study which was $415,000 over two years and our main aims for our team were to determine what are the health effects if any associated with living in a house with loose phyllospestas. We had four components and over the last two and a half years we've released reports specific to each of these components. So the first was a descriptive study of mesothelioma. These are reports of mesothelioma cancer to the ACT cancer registry and that allowed us to look at trends in mesothelioma over the time that that registry had been existed. We then conducted two focus groups, one in the north of ACT and one in the south to look at people's lived experience of being in these houses and hearing about the species contamination. This fed into a cross-sectional survey which no doubt many people in the room will have participated in where we actually went and asked people about their potential exposure to asbestos and also their perceived health effects and their emotional and mental well-being. Then finally the data linkage study which is probably the most important of all of these studies because it actually gives us a measure of risk. So the first component was trends in mesothelioma and this is a graph just showing the the total number of cases over a about a 20-year period 140 cases with 81% being male and you can see on this chart the majority of cases are over the age of 55. If we look at the trends we compared the trend in the ACT and the the rates so the number of cancers per population over time and you can see there's an increasing trend of mesothelioma over time in Australia that is in part due to the the actual increasing rates over time from exposures 30, 40, 50 years earlier and also the performance of these registries that are capturing the data they've got better over time. But you can see the the line along the bottom which is the ACT it increased to at the end of the period so in 2009-2011 to be to be a similar rate to that of Western Australia and you can see that we've excluded Western Australia in this chart that is because Western Australia has higher rates of mesothelioma than other states because of the witnum asbestos mine which resulted in a large number of mesothelioma cases and the dotted lines here at the beginning and at the end due to incomplete data. Then the second component was focus groups so this is where we we basically got people to come together in two venues in the north and the south of Canberra and talk about their concerns about physical health risks particularly children's and partner's health and their immediate health concerns so any the psychological distress of leaving home and any potential stigma of leaving a Mr Fluffy home or living in a Mr Fluffy home and I'm just going to show a couple of comments from residents and I know that these are really common to people who've lived in these homes and some of these sentiments so well we've been crawling around under there for years so my concern is what is going to happen to my son is 21 and in 20 or 30 years time is he going to discover he's got lung trouble that's my concern another person said I had six areas that had to be remediated and I had bubbles set up inside our house and we had to move out while that was being done I had no bathroom in the house at all for seven weeks in the middle of winter and we had no clothes and no laundry and then finally we'd prepared the house for our retirement and older age and suddenly all our plans have gone bust yeah so they're really and there were many more like that and when you see the the the kind I think probably the big effect that we did observe from those focus groups was the loss of community and loss of neighbourhood and it wasn't just about a house it was about an environment and all the things that happened in those places whether it was a garden that people had established or dogs and cats that they'd buried in the yard so the third component was following this and it was a cross-sectional survey which we wanted to generate information for understanding so the key things we were looking for was exposure to asbestos health related concerns we used an online questionnaire which was distributed through the task force to residents who were on the register between May and June 2016 and as a result of that we had about 363 current or recent residents respond from 262 households and there were also an additional 199 people who lived in these houses a long time ago but were not part of the buyback program and this is just showing data for current and recent residents and you can see here that it was very common for people to enter the roof space and the subfloor space in houses so in terms of roof space there was quite a big difference between men and women 40 percent of women had entered the roof space and 85 percent of men so in terms of potential asbestos exposure 53 percent of people reported asbestos being in the living areas and 10 percent reported being advised to vacate 82 percent reported renovation and during renovation 89 percent lived in home during renovation 41 percent involved residents themselves and no one used precautions for all renovations it's important to note that this survey is a fairly small proportion of all the people who lived in these homes 363 people from 290 odd homes so we may be getting a skewed view of exactly what happened but some of these figures correlate very well with other sources of information such as the where asbestos was found in the living areas in terms of psychological distress this is a chart showing psychological distress a measure of psychological distress based on a series of six questions about how people felt on a daily basis and you can and we've compared it to the ACT population using a different measure but similar and you can see that it's certainly a much higher rate of high emotional distress particularly in younger age groups that add into 24 year olds these are people that were concerned about their health but overall higher rates of psychological distress and 32 percent of people reported that they sought professional help either physical or mental and as I said it's important to recognise that these results reflect those people who responded to the survey people who didn't may be very different and certainly the discussions I've had with a number of people particularly people who lived in these houses some years ago they don't necessarily feel as concerned as what some of these results might might show that said we there's clearly a high level of distress amongst people who responded to the survey so I'm going to hand over to Dr Rosemary Corder now and she's going to talk about the fourth and most important component of this study I should just start by saying that all of these results have been put on the website so if you go to our website we should give you the address at the end if you haven't already visited it and the full results can be downloaded if you're not keeping up so this was the study that we've actually just finished and we released just about four weeks ago the data linkage study and I'm sure some of you have read about it and the purpose this study was really to look at the risk of mesothelioma which is the main cancer we're concerned about and other cancers in residents who had lived in these affected properties so the Mr Fluffy houses now why did we do this we know that the best cause is mesothelioma we know it may cause some of these other cancers so why do this very big study it's because we actually don't know extent to which living in these houses is associated with cancer to our knowledge there's been no studies in the world that have done this so for instance in North America in Libby Montana they have they've mined some vermiculite which has asbestos fibres in it so there's millions of houses in North America that are filled with a lot of asbestos insulation and there's never been studies about residents in these properties so there's been studies about people who mine it who put it in but not people who live in these houses so it was felt that this is important to at least find out what are that health risks potentially with living in these houses so i guess that's the why so so what did we do so in this study the main aim was to compare people who lived in a Mr Fluffy house to those who didn't live in a Mr Fluffy house for these selected cancers and again i will state this state that's outset that it's a quite a tricky study because even though mesothelioma is strongly associated with asbestos exposure the vast majority of people even who they're heavily exposed in occupation do not get mesothelioma it is a very rare cancer so here we are trying to pick up an association that is something fairly rare all right even in heavy exposures so we've known about this from occupational studies all right so for noon minds for instance and the workers that have used in worked in ship building yards so we were trying to pick it up of rare cancer in people who'd lived in these houses compared to people that hadn't so that's the first group the second group there is lung ovarian laryngeal pharyngeal stomach and colorectal cancer we loosely group those together because these are cancers which are not in from previous evidence from these occupational studies haven't shown a really strong link but there's definitely been some link in some studies particularly for lung ovarian laryngeal we believe it is caused by asbestos but again most people who get these cancers haven't had an asbestos exposure all right but it is there is some evidence for association and with pharyngeal stomach and colorectal the previous evidence suggests there could been association but it's not the evidence is actually not that strong but we thought we should look at it and then we had the third group which what we call control cancers so bladder kidney melanoma prostate and we put those in and the whole idea was there if we were going we didn't really expect to find anything of these all right we'd throw them in and say if we don't really expect to find that there will be an increased risk we expect to find if there is an association we expect to find it with mesothelioma we may find it with the second group and we don't expect to find it with the third group so that was our upfront hypothesis if you like in terms of scientific language so how do we do it so we did a link data study again you can understand it's quite tricky it's a disease with a long lag time that that it's rare and that it's quite difficult to find people and follow them you can't just interview people and say you know have you got cancer a lot of people have got cancers have died subsequently so we did a data linkage study what does that involve so for this one we use Medicare enrollment data and as you would know that most people in Australia nearly everyone in the population is enrolled in Medicare so on the Medicare data file you have names addresses data births so you can actually find out whether people have ever lived in the ACT I will say at the outset some people start to feel a bit nervous about thinking oh you've got all my details we don't have those details so these medical enrollment files and all the details I'm going to tell you about with linkage is they're linked by a third party and we never see the names addresses dates of birth we get the health information we get an ID number that doesn't really mean anything but we this is all confidential by the time the data gets to us so from this medical enrollment file we could actually pick up that there was actually over a million people that have lived in the ACT since Medicare began so we couldn't go back before Medicare began obviously what that was in 1983 we thought that was quite interesting in itself in the population it's only 400 000 but over that period of time over a million people have lived at some stage in the ACT some people obviously many people have moved on we're able to then link that to the address the list of effective residential properties so we use the task force list for that and on that list many of you'll be aware that there was 1023 properties that are publicly on that list and there was additional 66 addresses for houses that weren't on the list because they'd been demolished before the list was established for instance the houses that were in the bushfires were included in that list so we think we captured all the houses that had Mr Fluffy insulation and certainly the ones that were known we could link those two and then you could work out whether someone had lived in a Mr Fluffy house or not so from that we could ascertain that there were just over 17 000 people in the ACT since 1983 and up to December 2013 who would ever lived in one of these houses so again I think that's a really quite a fascinating bit of information we know there's over a thousand houses but at some stage over 17 000 people just since that time have actually lived in one of these houses so potentially quite a few people have been touched by this situation and then there was over a million people who had lived in the ACT at some stage but hadn't lived in one of these houses they lived in another house. Then what we did was link to the Australian Cancer Database so this is an incredibly valuable resource that is held by the Institute of Health and Welfare the Australian Institute of Health and Welfare and they also did the data linkage they're a Commonwealth accredited data linkage authority and all those data are fed in from all the states and territories so in Australia it's mandatory to report cancer a malignant cancer so it's a fantastic resource because we know that if you have been diagnosed with cancer it should be reported to one of these registries and again as Martin acknowledged at the front we do really acknowledge all the cancer registries around Australia because for each of them we have to get permission to use those those data for research too which we get got and I thank Sue Trevena in the audience who actually was on the study team and had to do eight ethics applications to get to get these data so it was quite a bit of work but well literally worth it so you link those and then you can say of all these people some of them had a cancer and some of them didn't all right and we know over that time there was about 60 000 cancer diagnosed amongst these million people that lived in the ACT of course we also had to link it to a death index and this wasn't because we were actually interested in working at mortality rates or death rates but we we needed to know when people had died because obviously if someone's no longer alive they can't get cancer so that's important when you actually calculate rates of disease and in our sample we had over 65 000 people die over that period of time so what did we find so mesothelioma again is the focus because that's the one if we're going to find something we expect to find it with mesothelioma we had 285 cases of mesothelioma so that's in that 30 year period that we studied now you might remember from that early slide there was 140 cases only and that's because most of the cases over half of them were actually registered outside the ACT so you can see the value of going Kent Australia wide so people had lived in the ACT but subsequently had moved away and then had their cancer diagnosed outside the ACT as you'd expect most of the cases were male we know that from previous evidence that was no surprise that 86% were male or 239 cases and the average age was 67 years and of course you can see that the number of cases grows up over time what did we find for Mr Fluffy's so we actually found a total of seven case result together and Mr Fluffy residents so of those in male residents sorry not in females so this is in male residents there are about eight and a half nine thousand male residents who had ever lived in a Mr Fluffy house in that period and seven of them had developed mesothelioma in that time period actually translates to a rate of 2.5 times higher so that that figure for some people will sound scary for others they think it's not a big deal how do we get that figure what you do is you calculate the rates in the rest of the population who haven't lived in the house and you adjust for age because the ages can be different and you say what would the rate look like and when you do that you get a rate that's two and a half times higher in the Mr Fluffy residents and that was significant so we do some statistical tests I haven't put those details up tonight and that shows that statistically significant which means that that's unlikely to be a chance finding that's probably a real association between Mr Fluffy living in a Mr Fluffy house and developing mesothelioma what does that mean in absolute numbers again I think it's really important 2.5 times can sound a lot but it means that there was four around four excess excess cases over a 30-year period in men so you follow these people for 30 years and we think there's about four cases that occurred that wouldn't have occurred if we didn't have Mr Fluffy that's our estimate and there was no cases in women who lived in these houses in the study period so we only found it in men what about the other cancers so we also found elevated rates in residents of colorectal cancer so in men the rate of colorectal cancer was about 1.3 times higher so about 30% higher than in people that had not lived in these houses or men had not lived in them and for women we also found an elevated rate for colorectal cancer about 1.7 times higher I'm going to go on and explain those results in a minute and with prostate cancer which was a real surprise because this is remember one of our control cancers we weren't expecting to find something and we found that prostate cancer was elevated in the men again not much just a little bit 30% higher but we did find this so we report it but for all the other cancers and we looked at 11 cancers altogether there was no association no significant association between living in a house and the rates of cancer in other words they were the same or statistically the same in the residents of Mr Fluffy and the non-residents so it's really important to keep in mind and if you like reading reports this is detailed in the report there are lots of caveats around these results right these are the best available data we think we had but it's what we call observational data this is not an experiment we don't say we're going to put you in one house and put you in another house see what happens over time all right and randomly assign you this is just what we call observational data we're reporting what we observe so there could be other explanations for the findings one is as you as you can appreciate we've got incomplete data the Medicare data was incredibly valuable resource it was fantastic the Commonwealth gave us permission to use it but it only started November 1983 what about the people that lived in Mr Fluffy house before 1983 and then moved out of a Mr Fluffy house we would have classified those people as having not lived in one all right so straight away we've got people who were categorised the wrong way not all cancers have been captured so they captured really well from from about the mid 90s onwards in ACT from all states from 1980 onwards right because the reason is that cancer's been mandatory over the whole period I'm sorry the cancer registry's been in place since not the early 1980s in all states and territories but it's only been mandatory reporting the ACT since 1994 so there will be people that may have got mesothelioma or the other cancers who we haven't captured in our data okay we don't expect those differences to be different between Mr Fluffy and non Mr Fluffy residents all right what we call an equal bias there's other things we have to think about this is observational data so the big one is we had no information occupation all right so we found seven cases we think four excess cases of mesothelioma but we don't know we can't rule out that they weren't occupationally based cases we can't say that they didn't get it from working in a mine or in the ship building industry we don't have that information we have no reason to believe the occupational profile of the Mr Fluffy residents on average would be any different to the non Mr Fluffy residents so all we can say is we think on balance there are excess cases but we can't prove it with the other cancers importantly with mesothelioma the the important thing about that is there are no other known risk factors all right if you've got mesothelioma the only thing we really know that causes it is exposes it to excessive form fibres but with these other cancers are there other risk factors all right in fact ones that are much stronger so for colorectal cancer smoking increases your risk for diet increases your risk for instance we don't know what though that profile was like in our Mr Fluffy and Mr non Mr Fluffy residents so we cannot rule out that other there were other reasons to explain that increased colorectal cancer rates and that's pretty important with prostate cancer there's a real bias towards diagnosis if you're tested because a lot of people have prostate cancer would never know it unless they're tested so it could be that maybe Mr Fluffy residents were more likely to get tested than non Mr Fluffy residents we don't know so we have to be a little bit more circumspect about those findings and of course chance when you do a study you could just by chance find differences in rates all right again it's it's we do statistical tests to rule out the that possibility when these are statistically significant but you can never actually say it didn't just happen by chance and we could have missed some cancers just by chance and this is really important to put in the context of previous evidence so with mesothelioma yes we found this elevated risk and where you feel a bit more confident that that's possibly a true association because the link from other studies has been very strong we know from occupational studies a very strong link with mesothelioma with colorectal cancer again why we're much more cautious by cautious about that result is that the prior evidence has not been that strong even when you've had very strong exposure in occupational settings the the risks are often not elevated in these occupational cohorts so we're a bit surprised to find that we didn't expect to find that you'd get a colorectal increased risk when the mesothelioma was 2.5 when they found that increased risk in other studies it's been when mesothelioma risk has been say a 30 fold risk in occupational workers and you might get a 1.5 fold risk in colorectal so it didn't quite pan out how we thought it would but if we did find it and the same with prostate cancer previous evidence suggests that there is actually very little evidence or none for a link with asbestos so that was a surprise finding but we can't dismiss it because it's still a plausible finding so we've reported it but we really want people to be very cautious about assuming it's causal and we know it's you know possible that we we know even after mediation there was fibres left in the houses they were founding 60 of the living rooms of houses this could still be a real finding so the key messages before I hand over to Bruce to to put a bit more meaning around some of this is that living in the house was associated with the increased risk in mesothelioma in men but not women overall though the absolute risk is very low association was weaker than occupational studies so it's 2.5 fold risk not the very you know 20, 30, 45 fold risk that you get in occupational studies and we think that people often ask why men are not women and it could be that we don't know but it could be because men were much more likely to go on the roof space or renovate compared to women so maybe it was just a heavy exposure for some of those men and again we're just going to with the raised levels of colorectal and prostate cancer unexpected was it study or is it a real association and we're not sure so on that note I'll hand over to Bruce who's going to talk about the results a bit more I guess this is the question that a lot of you have come hoping for an answer I'll try to answer it and we'll all be happy to ask answer questions if if I don't succeed okay it seems to me that for most people mesothelioma is the big issue with asbestos it's asbestos is the only core known cause of mesothelioma and it can in very heavily exposed people turn what is usually a rare cancer into a rather common cancer so it's very potent in its capacity to cause mesothelioma much more than it can any other kind of cancer but other cancers of course may be more common and therefore the increase is still quite important they are this result is the one as rosemary has made very clear is the one in which we can be most confident that this is almost certainly telling us the truth about what's gone on there's still some uncertainty about that the total number of mesotheliomas are small and and so one could argue that we don't absolutely know for sure but generally speaking when you have asbestos exposure and you see more mesotheliomas it is assumed that those mesotheliomas were probably a result of that asbestos exposure and as I've already suggested this is the result I think that's most likely to cause people concern it indicates that some people who lived in Mr Fluffy houses have been sufficiently exposed to asbestos to increase their risk of asbestos related disease so this was not a trivial exposure it was an exposure that looks like it has an impact an impact which perhaps we yet haven't measured as accurately as we might eventually be able to and so here it is just to remind you rosemary's already given this to you men who had ever lived in a Mr Fluffy house had a higher risk of mesothelioma than other male ACT residents so we're comparing ACT residents living in a Mr Fluffy house with other ACT residents the relative risk of mesothelioma was 2.54 so that's our best estimate of what it is a two and a half times increase in risk with a confidence interval that gets down to only just a two percent increase in risk up to a five-fold increase in risk so there's a bit of uncertainty about exactly what that number is but our best estimate is 2.54 now epidemiologists love relative risks they're used for establishing cause and effect but they are a relative measure in the sense that they're comparing one group of people with another group of people they don't tell you really anything about how important is that to you how big is the risk what is your risk of getting these ethelioma if you lived in a Mr Fluffy house for that we need what is called an absolute measure of risk and it says this is how much your risk is of getting something a cold next week or a headache in the next three minutes probably several people feeling a bit headachey at the moment so let's look at an absolute risk the measure i'm going to use is a measure that the Australian Institute of Health and Welfare routinely uses now in reporting cancer incidents and mortality data within Australia and that is the cumulative risk of having each kind of cancer by the time a person gets to age 85 it's expressed as one in some number like one in 64 one in 64 people if they live to 85 years of age will have been diagnosed with something or other is that terminology that you feel comfortable with familiar with i'm seeing a haven't seen it seen anyone shaking their head so and lots of nods so perhaps it's not bad anyway so and this is how we might state it and i've given a real example here in 96 men who live to 85 years of age one has a brain cancer diagnosed sometimes during their life that's that's the way you can understand these numbers now you can express it in a different way you can say well let's just turn that around and say well how if i had a thousand people thousand men how many of them would get a brain cancer by the time they get to 85 years of age and the answer is 10 approximately i've i've rounded all of these numbers um to whole numbers and so 10 per thousand one in 96 are essentially the same information just expressed in different ways so now let's look at some of the numbers so let's start with all Australian men what is the cumulative risk that an Australian man will develop a mesothelioma by the age of 85 years it's one in 137 that's actually quite a high figure globally because of the witness experience and the fact that Australia has been one of the heaviest users of asbestos in the world as a population and it's not hard to see all the fibro houses and all the fibro water pipes and things like that so a lot of asbestos have been used in Australia so that that's relatively high or it was very high on a global scale in all in in ACT men it's actually a little bit lower risk it's one in 163 the bigger second number the lower the risk and we know that from the data that rosemary show that on average over that period through to 2011 1994 i think it was 2011 the rate of mesothelioma in the ACT was 84% of that in the whole of Australia in other states of Australia excluding Deligoy men in Mr Fluffy houses 1 in 64 so that's the absolute figure to attach to being a man and living in a Mr Fluffy house is that 1 in 64 of those men if they live to 85 years of age will develop mesothelioma now i'm saying this very definitely you need to kind of think some confidence intervals around those numbers as there are around the relative risk but that's the best estimate that we can make now if we split up those mesotheliomas into mesotheliomas that were caused by asbestos in a Mr Fluffy house and those that were caused by something else probably some other asbestos exposure in the workplace living in Canberra living somewhere else the risk of getting a mesothelioma due to Mr Fluffy house asbestos is 1 in 105 and for other causes or other sources of asbestos exposure asbestos exposure 1 in 163 so i guess these these are the numbers do we have a pointer we have a pointer doesn't matter these are the numbers that are the most important to think about if particularly if you're a man you lived in a Mr Fluffy house then our best estimate on the basis of these data is that you have a 1 in 105 chance of developing mesothelioma by the age of 85 years now i've put here the same numbers but expressed in terms of numbers of cases per thousand just in case some of you find that helpful i won't go through it in detail the way i just did but we can point out here that nine men out of a thousand who live in a Mr Fluffy house well we estimate developer mesothelioma by the age of 85 years now it may be a bit difficult to you and i think we all find this difficult to say well what does what does 1 in 105 actually mean in in in in real terms how likely is that does it mean i'll likely be diagnosed tomorrow and one of my friends or you know i'll hear about in a few weeks time and i thought i'd give you something that you could compare those numbers with that perhaps you you have greater experience of shall we say than people getting mesothelioma and that's some of the commoner cancers but these are now all much more common than mesothelioma they're all cancers that tend to be quite nasty and what you can see is that mesothelioma is there in the same ballpark um or mesothelioma in in in asbestos exposed men in the act same ballpark as anyone in the population having a cancer of the esophagus or a brain tumour um it's a cute myeloid lekinia less frequent but you can see it's something like lung cancer much much more frequent and you can make the same comparisons in the numbers 100 per thousand there we are there was uh around about nine four mr fluffy house mesothelioma 10 for brain cancer six for acute myeloid lekinia 12 for esophageal cancer then of course lung cancer coming up with 77 so maybe that just gives you a bit more of an idea of of how frequent those kind of numbers mean now there's a bit of a catch to all of this and that is that we may be still quite early in the evolution of mesotheliomas caused by living in a mr fluffy house and so things could change the statistics could change as more cancers are diagnosed and this is an illustration of what happened in men who worked at wittner now there are certain similarities there mr fluffy houses or mr fluffy started work 1968 so after 40 years we get 2008 so we've between 40 and 50 years since then and here we've got figures going over 40 or 50 years there it was exposure from 1937 to 1969 66 i think and and then no more exposure since but the last exposure to a mr fluffy house has actually been quite recently that's not happening anymore but it was happening up until it quite quite recently so what but what we see here is a flattening out after about 40 years the risk the rate the absolute rate of mesothelioma in the wittner workers went up for around 40 years starting to flatten out so for those who lived in a mr fluffy house back in 1968 then their risk is probably not going to get any greater but for those who have lived more recently in a mr fluffy house there may be still 10 20 30 years of rising rates before that plateau comes about so those numbers that i've shown you those risks are probably under estimates of the true risk it is of course possible to repeat the kind of study that has been done and reported just a few weeks ago in the sense that you really just not so much repeating it you bring it up to date the mechanisms that were used to do what was done can be can be re-invoked and brought up to date and so it would be well in time as the numbers grow not only will we start to see where it's going to but it may also become possible to estimate by statistical projection and knowing how it evolves with respect to wittner where it's ultimately likely to get that may not be something you really want to know about but it is possible if that was what the community thought it wanted and that is all i've got to say thank you