 I would like to welcome everybody tonight to the interdisciplinary panel discussion. The subject is a collaborative approach to cancer, survivorship and mental health. We have a very talented panel here tonight, and I will just briefly go through each panel number. Meg Winderman is a survivor of recurrent Hodgkin's disease and hormone positive breast cancer. You will be able to see her full bio on the MHPM website. But I'd just like to ask you, Meg, is resilience a family trait in your family? The ear possibly, I suppose it is, yes. Because it comes through very much in your story. Yeah, I think it becomes learnt too after such a long journey. You learn how to survive. Yes, yes, yes. Thank you very much. The next person that I would like to introduce is Associate Professor Michael Jefford, an oncologist. Michael is based in Melbourne and is associated with the Peter McCallum Cancer Centre. He is also a senior clinical consultant at Cancer Council Victoria. Michael, may I ask you, when did you first become interested in the psychological aspect of cancer care? For a long time. I thought I was going to be a psychiatrist before I ended up changing courses. So I was interested in psychiatry as a medical student, and I guess I've always been interested in the psychological aspects of healthcare. So I've probably always combined some sort of interest in psychosocial care with clinical oncology care, and a lot of my practice and a lot of my research has that kind of angle. Excellent. Excellent. Thank you very much. And the third panelist we have tonight is Dr Craig Hasard, a GP. Craig is based in Melbourne and Victoria. Craig also has a great interest in the mind-body continuance and mind-body medicine. Has that been a lifelong thing, Craig, or is it something that you developed during med school or after you qualified? No, I think I maintain my interest from, you know, when I was in secondary school and just being aware of my own body and mind and noticing that they're related. So I think I maintain that interest in spite of my medical education, not because of it. That's a very, very good answer. And the fourth person I'd like to introduce is Professor Phyllis Buto. Phyllis is a clinical psychologist. She has built up a team of researchers based in New South Wales and throughout the country and primarily works with the University of Sydney. And she's interested in developing psycho-oncology research in Australia. She's worked with many different disciplines and her present research interests are within the field of health psychology. Again, may I ask you, Phyllis, how did you first become involved with cancer and medical care and the mind-body continuance? Well, I think like many things, it was a certain amount of luck in that I got out of my PhD, which had actually been on eating disorders, looked for a job. And the first job that I got was working on a cancer research project. And I've stayed ever since because it's a fantastic area. Cancer is something that affects everybody in the community. And there are, you know, so many issues that people face in this area. I've never got, you know, there's never a dull moment in terms of research and the issues that need to be addressed. So I've stayed in it ever since. Thank you. Thank you, Phyllis. And the final and fifth person on our panel tonight is Professor David Cusane. And David is an academic psychiatrist, a psycho-oncologist researcher and author. And he's currently the head of psychiatry from Monash University in Australia, but has recently taken up a very senior position in the U.S., working in oncology and psychotherapy. He has written many papers. He's the author of many books. His bio is available on the MHPN site, and we welcome him here tonight. David, may I ask you, why did you decide to do psychiatry? Good evening, Michael. First of all, I spent a decade in general practice, actually, and then came to psychiatry. The last 25 years have been a combination of psycho-oncology and palliative care. And you said I was just heading off to the U.S., but indeed I've just come back from a decade in the U.S. after having had a period of time working in palliative care with the University of Melbourne. I went across to Sloan Kettering Cancer Centre for a decade and then have been for this past year back in Australia. We're very delighted to be back here working again with Monash University, which was one of my alma mater. Thank you very much for sharing that with us, David. That's very instructive. I'd just like to introduce myself. My name is Michael Murray. I'm a GP in Tanswell. I have facilitated many of the MHPN webinars. My main interests are in family practice, mental health care, and I have worked in Headspace, which, as you know, is the Youth Mental Health Initiative presidency being rolled out through Australia. I would now just like to move on a little bit and we'll just go to just some grand rules. We're very, very privileged to have you all log in tonight. We have had over 850 people register. I think we're up to about 250 people who've logged on. More people will log on as the evening goes on. Some of us have just gone into darkness. Some of you have been in darkness for an hour or so. Some of us are still in light in Western Queensland, Western New South Wales, South Australia, Western Australia, and Darwin. Some are on their way home. Some of you may be on your iPads on a train somewhere logging into this. So we welcome you all here tonight. We are more than happy for you to post comments into the chat box. Your feedback is very, very, very important to us. We have three learning objectives for tonight. The first is to better understand the mental health indicators and the context of cancer survivorship. The second is to identify the key principles of the featured disciplines approach in screening, diagnosing and supporting people who have survived cancer and may be experiencing depression and or anxiety. And thirdly, to explore tips and strategies for interdisciplinary collaborative care for people who have survived cancer and may be experiencing depression and or anxiety. Now, we are just about to start our presentations. And the order of presentations will go in the order that I have introduced the panelists. And I am now going to move over to Meg and ask her to present her presentation. Thank you, Michael. Do you need a disabled parking sticker for when you go home? Have you tried music therapy? In over 20 years of various cancer treatments, hospitalisations and recoveries, these were the only approaches made to me by mental health practitioners. As both an inpatient and outpatient, doctors, nurses and treatment staff were caring, kind and concerned. They asked me how I was feeling physically, but never how I was coping, how my partner or my kids were doing, whether any of us might need support. Survivorship is part of the cancer journey. After the unpredictable rollercoaster ride of the treatment phase, the doctor's visits, the biopsies, the scans, the chemo, the radiotherapy and the surgeries. Survivorship is about the slow, painful return to health, the follow-ups, the odd and unexplained side effects, and ongoing concerns over the tiniest aches and pains, the impact on partners, carers, family and friends. Their concerns when a new symptom or potential issue emerges, the emotions surrounding annual check-ups. Survivorship is about restarting your life. It's about understanding that this immediate threat to your mortality has passed. It's about accepting the changes, understanding the new normal, incorporating the scars, the loss of function and the limits, and about waking up each morning to face a new day. Over a lengthy journey, practice and methodologies change and improve, where 20 years ago support services were not available. Today, cancer patients and survivors are offered a wide range of resources and supports to assist, educate and inform them. I hadn't heard the term supportive care screening or distress thermometer until I began to volunteer for the survivorship centre at Peter Mac. Recently, when I felt I needed to talk to someone prior to making a decision around mastectomy, I had to ask the breast care nurse whether she knew of a psychologist or mental health worker who focused on women with breast cancer. The information had not been forthcoming as a matter of course. I wonder whether this has been due to the fact that apart from a lengthy hospitalisation for a stem cell transplant, I've been a user of the private system. Mostly it seems, and certainly in my experience, supportive care is not a term well utilised around cancer and private practice. None of my oncologists or my GPs ever suggested that I might need support around my emotional or psychological well-being. Maybe it's because I'm confident, well-spoken, capable, an English speaker, perhaps the lack of tears and histrionics. Did my doctors and medical teams feel that I was okay, coping, well able to advocate for myself? No one ever inquired. Or was I lucky to have pushed on doors and found answers where I fear many others do not? And what happens to the others, the ones who don't have the words, who are intimidated by the system? Do they muddle on, fall through the cracks? For me, there are a number of elements that speak loudly arising from over 20 years of cancer treatments and survivorship. Supportive care and the apparent inequality with which it's administered, the lack of interdisciplinary coordination and communication, the lack of any record care plan to link the various care and treatment strengths with the patient and each other. It must be difficult to identify survivors who might be experiencing anxiety or depression if after the treatment and follow-up stages of the cancer journey, the patient is sent back to their GP with little liaison from the oncology team. My sense is that the ownership of a care plan would create that dialogue and empower survivors. They and their relevant healthcare professionals would all be armed with a tool that would inform each survivor's future, not one that would pathologize their survivorship, but one that would assist them to find a starting place to answer if and when necessary. Issues of case coordination, management and advocacy might be discussed openly in pursuit of a holistic bio-psychosocial model. As each patient is an individual, each plan would be flexible enough to be modified to meet the particular patient's needs and information requirements. Many cancer patients move into survivorship with no need for additional follow-up or support. Treatment and surveillance completed, they transition on to the next phase of their lives. As a survivor, though, it's easy to get lost to the system. You may move from one cancer stream to another. Side effects or late effects may require the services of different specialists. The demands and changes to general practice allow less time for relationship building, for follow-up, for talking. If one regards survivorship as the post-treatment phase of the cancer journey, who undertakes the management of the survivor? The oncologist, the cancer hospital, a survivorship clinic, the practice or clinic nurse, the GP, or the survivor themselves? The answer to this question would go a long way to changing the system and offering pathways for identifying and referring survivors who might not be coping. As healthcare professionals, you are in the unique position to effect change, to smooth the rollercoaster ride, your hands on and offer your skills, your training and empathy to your patients. You're in a position to create the dialogues, to work collaboratively, to establish networks. If you are mindful of your patient's holistic needs, if you listen to them and hear their concerns, you can help them to find the supportive care they need. Thanks, Michael. Thanks very much, Meg, for an excellent presentation, which is making us all think. We will now move on to Michael Jaffer, who will make his presentation in response to Meg's story. Thank you, Michael. Thank you. Thanks very much. Thanks very much. Very difficult to follow, Meg. She always speaks so well, and so... Oh, well. ...onionally. ...onionally to reflect on what Meg's just said. I'm going to be speaking. I feel that my presentation is a little bit dull in comparison, but I'll just try and give a little bit of a perspective on issues in terms of providing better care for people after they finish their cancer treatment, and partly to reflect on Meg's story that I'm sure most people will have had the chance to read. I think of there being a number of challenges in terms of providing improved care for cancer survivors. And by cancer survivors, I'm really, as Meg suggested, that the term has been used in different ways, but we tend to think of cancer survivors, particularly in Australia. Largely, we use that term to refer to people who have completed cancer treatment, and often the terms used to describe people who have had a good outcome and appear to be cancer free. So one of the happy challenges is that we have a very large and growing number of cancer survivors, and that's partly because of increased detection, but it's also because of better treatments. We'll come in a moment to discuss the breadth of issues that survivors can experience, but Meg's story, I think, has highlighted already a huge number of issues that people can experience immediately after completing treatment and in the weeks, months, and years afterwards. That's, of course, important because an approach that's one size fits all isn't going to suit. There's an enormous variation between survivors, and so we need a system that's flexible to that. Having said that, we have to recognize, and I'm sure everybody who's part of this webinar will be acutely aware of the limited health workforce. So the question then is, how do we use that most effectively to provide better care? A further challenge is that we have imperfect evidence and guidance. So how often should we be seeing people? What tools should we be used for screening? Who are the people that should be seeing cancer survivors? Much of this is unknown at this stage, or there's imperfect evidence. Press the right button. So a number of years ago, we were interested in understanding whether issues that Australian cancer survivors experience, whether they're typical of that that we know in the literature. And so the first box in the middle of the screen really is a paper about results from focus groups that we did with Australian cancer survivors and a range of health professionals to determine what are the issues that people experience in Australia. And I'll come to that in just a moment, but we use that information to inform the development of the first general information booklet for cancer survivors that's now a national resource available through Cancer Council. And we also use it to develop a DVD which at the time was the first DVD for cancer survivors as well. So there's sorts of issues that people experience and many of these you'll hear in Meg's story. First of all, people can have very varied reactions to finishing treatment. We know that some people know it's the time of great joy to have finished all of their cancer treatment and to be at the end of it. But many other people can feel quite lost and abandoned, particularly people who have had a lot of very intense contact with the cancer center, the hospital, they can kind of wonder, well, what happens now? In Meg's story, we heard about persisting side effects from treatment. We'll be discussing at length tonight about emotional and psychological issues that people can experience. There are side effects that can develop later, so-called late effects. Meg's story talks about damage caused by radiotherapy and also the fact that people can develop another cancer because of their previous treatment. And in Meg's circumstance, the fact that she developed breast cancer is strongly linked to previous radiotherapy and for treatment of lymphoma and it may well have been a consequence of treatment lymphoma. In Meg's story also, she talks about the impact on relationships and family and also practical issues in terms of return to work, finances, etc. However, and I'm sure we will talk about this, there is the opportunity and I guess that many people do experience growth and something positive from a very challenging and difficult experience. So, the quick plug for where I work at Peter Maxx, so Australian Cancer Survivorship Centre, in, I don't know whether you can see my arrow, but in the middle of the homepage, which actually now has Meg on the front page, but in the middle of the homepage, you can click on a link to the DVD that I talked about previously. I think that appears on the next slide. So, you'll see that there are a number of chapters on reactions to finishing treatment, coping, physical consequences, etc. So, you can see all that online and we're very happy to supply the DVD as well. So, thinking about how do we improve care, we recognise that care currently is not as good as it could and should be and we do have some guidance. This is one report and it has been very influential. It was produced by the US Institute of Medicine it's called From Cancer Patient to Cancer Survivor Lost in Transition and it was published in 2006. The person on the right hand side is Patty Gaines who has been very influential around survivorship and she's based at UCLA and she speaks in a video that's available on YouTube. I've just typed in From Cancer Patient to Cancer Survivor Lost in Transition but we'll supply you with a link to that. It goes for about 17 minutes and it's excellent. Talks about the sorts of issues that survivors can experience. The shortfallings in the healthcare system and although it talks about the US I think that they'll feel very familiar to Australian audiences too and it talks about some of the issues and some of the responses that they suggest including the use of survivorship care plans that Meg just alluded to. So, I just want to finally just talk about some essential components of survivorship care recommended by this Institute of Medicine report. So, in providing better care for people after completing cancer treatment we'd like to be able to where possible obviously prevent recurrent and new cancers but we'd also like to be able to prevent late effects. We want to be able to prevent that damage that radiation causes and we want to prevent it from causing second cancers etc. We would like to be able to conduct some sort of surveillance not just for cancer spread and recurrence but the sorts of medical and psychosocial late effects that people might experience. Again, we'll talk about that but we know that people can experience a number of issues and we can screen for those sorts of things. We should be intervening for medical problems such as lymphedema, sexual dysfunction, symptoms such as pain and fatigue, distress that can be just as prevalent in caregivers as survivors I'm sure we'll talk about that too and also these practical issues such as employment, insurance and disability and critically and again as Meg talked about the importance of good care coordination so people don't fall through cracks so that it's not just hit and miss and that needs to be good coordination between the survivor and their family but also providers in the community whether that's their GP or other providers as well as other specialists that might be based in a hospital, cancer center etc. So that's the end of my introductory comments back to you Michael. Thank you very much Michael that was an excellent presentation and covered a lot in five minutes so thank you thank you very, very much. We will now move on to Craig Hussis our GP for his contribution. Hello everybody. Good, I'll just move the slides on. So just from a general practitioner perspective I think that there's a lot that can be done and it sounded like from Meg's experience there were some things that would have been very helpful that either weren't asked about or weren't provided. Certainly a GP is one of the people who might be in a position to provide some of this other care but also linking in with a whole range of allied health professionals and perhaps support groups and community services that might add a lot of value to Meg's experience of going through cancer and the treatments but also to improve the quality of life as well. From an integrative medicine approach very often I think as doctors we focus on the physical and the medical therapies and as important as they are we can get so focused on that that we don't see anything else. And it's sort of like a selective blindness that I think we sometimes get and we're not sometimes aware of other things that could be provided where perhaps not asking the patient about other things that could be useful. One model that develop and we certainly teach our medical students at Monash University about is the essence model the essence of self-care and that's an acronym that stands for Education, Stress Management, Spirituality, Exercise, Nutrition, Connectiveness and Environment. And for me there are seven boxes that really should be thought of not as an occasion but as a standard part of care. And that can start right from within the hospital having the initial cancer treatment to start to put that on the agenda to think about after the event of going through the initial cancer treatments but also within the general practice when a patient seeks follow-up. Stress management really stands for the whole mind, body, sort of area and the importance of things like mindfulness, spirituality can mean a lot of different things to different people. So where we find meaning and purpose in our lives it could be through religion but for many people it's not through religion but it's through other things that make life meaningful like relationships and playing a part in life or making a contribution in ways that are important in the world. Meg's doing exactly that I think right now and in the kind of support that she's given to many, many cancer patients around Australia and probably around the world as well. For me that's spirituality that's meaning. The importance of physical activity and nutrition of course and these things have a significant impact on a person's well-being but also on outcomes so and how well a person copes with treatments and so these can be wonderful adjuncts as is connectedness our social support and relationships and the importance of a healthy environment not just the physical environment but also the emotional environment everything from the hospital to where we live the parks and the open spaces the social environments that we go into so environments are very broad concept. All of these could be applied to the essence of mental health as well that there's important things that from all of those categories that can impact on mental health and well-being and I would hope that one day that this sort of total or holistic or integrated care would be standard management and not an occasional add-on. I think that people can learn a lot about this from support groups and programs and they could be run within practices but very often there are lots of community groups that can provide this sort of support. One of the things that I've certainly had a strong personal and professional interest in is the role of mindfulness and I'm sure a lot of the the mental health professionals that are a part of this webinar will be very aware of it and actively engaged in getting training and teaching it. Mindfulness would be important I think for a whole range of reasons and each person might have their own particular motivation or context but for improving mental health and resilience coping not just with the disease but the symptoms and coping of the treatments because it has a range of physical health benefits so reducing the stress response improve immunity less inflammation changes in DNA function and repair so there's a whole fascinating area of research there. Enjoyments in life enrichment through more engagement of being more present and certainly acceptance and acceptance because life is changing so roles are changing what we can or can't do might be changing and one day for all of us sooner or later the whole issue of acceptance as well around death and dying and how can things like mindfulness help us to flow through that and not just to help ourselves but also for family and friends that have gone the journey with a person who's been living with cancer for some years. So these are some of the things that certainly the GP myself I'm very interested in but also working with some cancer support groups. I feel that a lot more could be provided for people with cancer. My experience has been that mostly these things do not come under the radar and many patients feel like they have to go outside of the healthcare system or conventional healthcare system to try and find these elements themselves and I would hope that many people don't put themselves at risk sometimes by flying blind in terms of maybe some time pursuing approaches and therapies that may not always be safe and healthy. So there are a few of my thoughts I'd like to offer in relation to Meg's case and put before people to consider in our discussion later on. Thank you very much, Craig. That was an excellent presentation from the general practitioner point of view and also from the integrator point of view and of course from the mindfulness point of view which I can see from the comments coming in from our participants is very much appreciated. We will now move over to you, David as a contrast for your presentation. To Phyllis. Pardon me. We will now move over to Phyllis our clinical psychologist for her presentation. I do apologize. So thank you, Michael. So I'm going through just some of the things that I thought about listening to Meg I think it really does remind us that having survived cancer is not an easy journey. There are challenges and it certainly takes time to recover from a cancer diagnosis and all of the treatment that that involves. And there's now been many, many studies that have shown that overall cancer survivors have poorer health than the general population not only in terms of long-term side effects and physical issues but also psychological and emotional challenges. And one of those issues that people who have survived cancer live with every day is the fear of the cancer coming back and it's a rare cancer survivor that doesn't wake up particularly on mornings when they have to go back and see the doctor with a level of anxiety about the cancer coming back. And for some people that can really prevent them from planning for the future and moving on. I think another emotional issue that Meg has alluded to is that the almost identity crisis that comes with being a cancer survivor it does change you and people struggle to find a new normal or who they are now that their cancer treatment is finished but they're still changed. And then people also need to live with the expectations of other people and work out how they're going to respond to that. Sometimes they're expected to be grateful because they've survived or heroic which they may not feel they are or they're expected to be just as they were before and as we just said that's really the case. And in addition to those things there are the long-term side effects that a number of people have already alluded to both the physical problems that people are left with such as lymphedema and long-term fatigue. They might have gone through a premature menopause they might have sexual difficulties as a result of treatment and they also may be at higher risk of other health problems which they need to live with. I also think that Meg's story really brings home the message that it's not just the cancer survivor that's affected by this whole experience it's also the survivor's family. And again we know from research that family members can be as distressed or more distressed than the survivor. They worry about how the survivor's coping they fear for the future both for the person who survived and for themselves. And they may have to have changed their role if the survivor can't do things that they used to do and there may be intimacy and sexual issues that they struggle with. And I think if the system fails patients that probably fails family family even more. And we even more rarely ask about how the family is doing so I think that's something that's worth discussing as well. Michael noted this and so did Meg that there can be positive outcomes as well and we do want to remember those. And certainly in a study that I and some colleagues did some years ago the majority of people reported at least one positive outcome as a result of their cancer particularly the women I should add. And as a result of the cancer people said they focus more on things that are important. They've made positive changes to their life. They feel they've grown as a person and they appreciate their relationships with other people more. So it can lead to some positive changes. Now Meg talked about the distress thermometer and if you haven't seen that this is a distress thermometer and it's a great way of avoiding people slipping through the cracks and unless someone asks or unless people feel brave enough to say that they want some support they often do fall between the cracks. So the distress thermometer is a single item where people just indicate on the thermometer how distressed they are. And if they score over around four that suggests that they've got enough to stress that it's probably something they need help need support with and need help with. And they can then take a whole lot of these boxes on the right to indicate what the issues are that are causing them distress which can help health professionals work out what they should be doing to better support that person. So in my view anytime somebody turns up in a hospital or in a GP's clinic if they had the distress thermometer thrust in front of them and they had the opportunity to just reflect for a moment on how they are travelling and give some feedback that might allow someone to suggest something that might be helpful we might let fewer people fall between the cracks. I did just want to finish reflecting on this by commenting on the fact that there are different models for care in terms of a multidisciplinary group such as ourselves tonight and this is one article which has explored that. Now this last slide is I'm sorry very busy but if you just focus on the figure in the top the first model A unfortunately is what often happens now where somebody develops cancer their GPs drop out of the picture the care focuses on the oncology team there's very poor communication between what's going on in hospital and what's going on in the community to I think the detriment of the patient and what this article is suggesting is that a better model of care is a shared model where there's care both in the community and through the oncology team which is not just the oncologist I should say but it could involve all sorts of allied health nursing care as well as medical care and that the communication between the two is achieved through as Meg said a survivorship care plan where everybody's on the same page about where that person is heading what sort of support they need what sort of follow-up they need and there can be communication and support between the GP and the oncology team if that's necessary so you know there are different models this is just two of them but I think we can also explore this further so I'll hand back to you Michael Thank you very much it was a very very interesting presentation and it's given us much to think about and finally we will move over to David our psychiatrist for his presentation thank you very much David Thanks very much Michael Thanks very much Michael it's been the case I think that each of the speakers have spoken about the longer term and late effects when I talk to oncologists about these they tell me that again and again they introduce these notions to patients when they first consent to treatments such as chemotherapy regimens or radiation therapy but I think we need to keep in mind that it's quite a stressful time for people when they're agreeing to those initial cancer therapies and it's often the case that they don't remember some years later that these particular risks have been considered and so that becomes part of our presentation tonight to emphasise the importance once remission is achieved once the primary treatment is finished to go back to the patient and really create a care plan that deals with and summarises all of those risks and works out management that flows on from there now people have talked about the fear of recurrence and make a self-comment that on how aches and pains occur through years and that of course brings what I call an existential threat the uncertainty of whether that cancer will return whether the threat of death will come back in the future and it's really a lifelong coping challenge to deal with that and we've talked about anxiety and depression being possible and I just pick up at the bottom of that slide on the potential impact on the family also these days as more and more familial aspects of cancer are being picked up and people are having genetic tests so that can also have an impact the work that Kevin Offenture has done across the US in following a very large cohort of adolescents children who are treated for cancer followed them across 30 years into adulthood tells much of the story of the potential problem of these late effects and we see that over 30 years these people three-quarters of them carry a chronic health condition and many have functional limitations and 42% severely disabled I've seen patients that have had two and three cancers occurring as secondary cancers 20 to 30 years after their primary cancer was treated and at a cancer center in the US like the Memorial Sloan Kettering Cancer Center in fact 16% of our new patient admissions were for second or third cancers rather than the first cancer occurrence and we anticipate that as the community ages that we'll see one in five people coming along with a second or third cancer and then our cardiac disease Excuse me David it's Michael Murray here we're just having a little bit of a problem hearing you is it possible to reposition your microphone a little bit? I'll bring that in a little bit Michael that's much much better thank you thank you for alerting me to that and here from the childhood survivorship study 17% of these folk carried problems with anxiety, depression, somatization where people are focusing on their body and worrying about those aches and pains so if we look at some of these post-treatment issues one point to make is that adaptation occurs across many months or years it's not necessarily a quick fix and a number of patients are so focused on their initial treatment that it's only when treatments finish that they start to come to terms emotionally with what's happened to them and they may spend the next two or three years putting all of that into perspective perspective it's very important of course to encourage survivors to move to active rehabilitation exercise is one example and this idea of bodily vigilance I think is highly understandable where people develop an ache or pain that they immediately start to wonder is this the cancer returning and bodily vigilance is important to in fact ensure that they get appropriate treatment but they can't magnify the effect of that worry and allow that to have a spoiling effect on their life and that's where I think psychologists and psychoncologists can be helpful with a cognitive behavioral approach to helping patients put those particular bodily symptoms into perspective and not allow them to become too much of a focus for worry we recognize that about one in five patients one year out after their cancer has been treated struggle to return to work and that shows some of the challenge of rehabilitation and all of this then points both the longer term and late effects to the need to build up a future care plan that has an emphasis on health promotion and wellbeing as we take the cancer survivor forward so they need help with all sorts of issues that may include really menopause sexual functioning of fertility problems many patients will need an annual thyroid blood test particularly if they've had radiation that's covered the thyroid area if they've had treatment with some of the modern lymphoma medications like Rituximab then they may have a need for increased vaccination to help them overcome problems like the flu and even pneumococcus vaccination is recommended to protect people against the development of pneumonia Patients I find when they develop a secondary cancer often have a concern was it picked up early enough and many of them won't have known that they could well have started surveillance at an earlier age than the general community and it very much depends on when their cancer was treated and if one then talks to their oncologist about what to do 10 and 15 years out it may mean that mammography or other sorts of tests cholesterol checks cardiac function tests are important to bring into a care plan and have them engage with the majority of people over the 6 to 12 months after their cancer is treated show a return to normal quality of life measure measures but their need for this screening and health promotion is really lifelong from that time forward so what I think we've got to help patients to accomplish here is the development of what I call a new health literacy about cancer survivorship that is a new understanding of what it means to be a cancer survival survivor and here I take Howard Leventhal's model of how patients understand their illness in a common sense way and Leventhal identifies these five key domains that patients need to think about as they address the concept that they're now a cancer survivor that that survivorship carries a risk across life it has a real identity like that there are timelines for their threats some threats will come on five years out, 10 years out some won't come until 20 to 30 years have gone by and they need to understand those timelines they need to have an understanding of what the consequences would be if they missed screening tests health promotion tests cancer screening and that links in very much with understanding the way that chemotherapy may put them at risk for perhaps a leukemia 10 or 15 years later how radiation therapy can produce a number of secondary cancers makes an example of a secondary breast cancer a thyroid cancer tongue head and neck cancer is a common when people have had mental radiation as Meg did and so all of this leads to the concept that illness may well be controllable and early diagnosis may be important if it's not preventable then we need to recognize that and get in and treat it quite early so that's been my effort to give a perspective of what's involved there Michael I'll hand back to you thank you very much David for an excellent presentation which has given us all much to think about now the next segment of the webinar we would normally have questions panel members posing questions to each other but this is such a broad topic and such an important topic that we've decided to just have a free flowing conversation and each panel member has given me some conversation starters but we're going to go back to Meg again and Meg I'd just like you to start the conversation in relation to something that you sent to us about limited referral and access to support of care could you comment on that? Sure my experience and my sense of moving the discussion along in this regard is that as I alluded to in my talk within the private health system of cancer care there is virtually no such thing as supportive care I have never come across it it's never been offered to me if I've ever needed any support of any thought I've needed to seek it out for myself and as I suggested earlier in my talk I've been able to do that I'm confident and I'm capable and able to ask the questions and knock on the doors my concern is that there are very very many cancer patients and survivors in particular who may fall through the cracks of the system they're not these things are not offered to them nobody is asking them how they are how they're doing and I wanted to help how the other panel members feel about how this may may be changed within the system whether it needs further education for oncologists for GPs for practice nurses what they might feel about it Michael you did mention too in one of your comments that you sent to us and that that there is a need for this is this just something that happens in the private system or does it happen in the public system as well and did you comment on this aspect of care? I don't think I can speak for the whole of either the private system or the public system but I think that probably many of the people who are participating in this webinar would say that it's very patchy regardless of where you are some people are lucky and they come across an individual or a center or a unit that has a particular focus on trying to identify issues and needs that people might have and Phyllis talked about the distress thermometer and certainly in Victoria the Department of Health have been keen to and certainly in the oncology setting to roll out screening for people affected by cancer now that might be people have chosen what sort of tools they want to use the distress thermometer has the advantage of it being very brief others have used different tools and I guess that I would say that I would agree with Meg that we need to ensure that this is front of mind and that it's not hit and miss but everybody has an opportunity to talk about how they're feeling and to express a need and whether that's through a needs assessment or a screening tool you know and I guess the issue is whether or not that's a very brief screening tool or a more comprehensive screening tool we can certainly talk about that and ideally people should have their needs assessed repeatedly I think that we'd probably all agree that as David said that you know people might be told things at diagnosis but that's a very stressful time and they're trying to take in a lot of things and so we need to come back to people and ask them again and particularly at critical points in the cancer journey at at initial diagnosis at the end of treatment at the time when disease might come back at different phases so yeah I would say that thank you so much thank you very much over here you'd be saying that a patient should in fact understand all the treatments they've received and have a clear sense of what's happened to them what their cancer's all been about and you were talking about the treatment and survivors care plan as a way of having that summarized that care plan should go out to GPs it should go to all of the people who have been involved in the person's treatment but what do you think about the patient actually carrying that themselves having their own copy of that so that they're empowered to in fact discuss that with any physician that they see in the future and use that as a tool to guide them as they go forward in survivors yep so look at the Institute of Medicine report and many others argue strongly for the use of survivorship care plans and that the survivorship care plan as you suggest is intended for all of the healthcare providers but critically is an important tool for that particular survivor and whoever's close to them I guess now we've done work and so has so have you and so has Phyllis about how do we operationalize this and you know if we think that there are potentially let's say over 700,000 survivors in Australia people start asking well how long does it take to summarize the treatment and how long does it take to do a needs assessment and how long does it take to discuss the care plan with a patient and in Australia and in many parts of the world people are saying it probably takes a couple of hours to do a treatment summary and an hour to discuss it and do we have the time to do that and that's that's I think that a big challenge in terms of I think we all believe that survivorship care plans are important they're very important for both survivors and for health professionals but we need to work out how we can actually operationalize this and a number of studies have also asked GPs or primary care physicians their views of the survivorship care plan and the Institute of Medicine care plan goes for about you know if you do all of that it's about a 15 page document and most GPs say they want something that's a page or two so we do need to work out how we can tailor the content to particular particularly to GPs and to survivors so that it's most useful for them It's Phyllis here I just like to also say though that I think it's really important that there is very wide recognition and endorsement given to the importance of supportive care and that means that it needs to be in guidelines that delivering this care and hospital accreditation so that people are rewarded for providing this sort of service I think that's very important for the private sphere in particular and until we have that sort of system wide change we're not likely to get you know real change and I guess the other thing I'd like to pick up on from what you said Michael was that we can look at ways of both educating health professionals to ask these questions and it often is just a quick question but we can also educate and provide patients with tools and one of the things that we've developed and found to be very effective is giving patients a question pop list so a list of questions that they can ask that they might not have thought to ask themselves or that are you know other people who ask or wish they'd asked and looking at a list of questions like that can often empower people to think of things they might not have thought of or wouldn't have the courage to ask when they go and see a health professional so I think they're sort of too there's a number of approaches that are needed here strategies that can empower people to look to ask for care and support when they need it strategies to educate health professionals but also system changes that that rewards health professionals for putting the time into these sorts of activities Can I interrupt Michael that I couldn't agree more Phyllis and Phyllis and David have been international leaders in communication skills training so I think that for the patient and survivor point of view question problem lists are a good tool and we do have a question problem list on the ACSC website and we've certainly been using question problem lists as a way of for survivors to guide the conversation and guide what's important for them in consultations as a tool and I guess that in terms of getting back to Michael your point that Meg had raised about limited referral and access to supportive care how do we actually get clinicians to ask and Meg pleaded that we need to be asking and we're not listening but listening as well as asking and I think that a lot of that is hopefully about communication skills training and raising awareness and maybe David or Phyllis would like to talk a little bit more about that May I just interrupt here it's Michael Murray speaking Craig has his phone as disconnected and as a GP I'm sure he would have much to say about care plans so on his behalf I can empathize with that study that you did where GP didn't want a 15 page document and can you is it possible to put it on one page well yeah yeah that's right so and the question is what yeah look I mean I think that it is possible and we've done things like that and some of the things that are included in the care plan around recommendations which are often recommendations for health maintenance or chronic disease sort of principles when we've asked GPs they'll say well this is our bread and butter we do this every day you know we talk to people about exercise and stopping smoking and you know support groups and these sorts of things and so that information may not be critical for GPs so we do need to think about what's the information that we really want to be able to communicate to GPs but also in a format that is that suits GPs because the Institute of Medicine idea of a survivorship care plan is not the idea of a survivorship care plan that most GPs in Australia have and so now actually have Craig back online so we'll just ask him to comment we've just been talking about survivorship survival care plans in an effort to coordinate care better and to get better assets out to survivors of cancer do you have any comments on that Craig? Well certainly GPs are very time-poor like a lot of health professionals and so for GPs to get more actively involved it needs to be something that's simple without too much red tape and so that the the time is really spent with the patients and providing information and those gaps of in their care and the better coordination rather than spending a lot of time with the forms and the paperwork I think too that and I'm sorry I missed about the last five minutes of conversation because the phone line dropped out but just to pick up on the last thing I heard too from Meg when she was talking about the gaps in care and I think that sometimes and I know that Michael is somebody is very committed to providing a much broader approach to cancer care but I think sometimes the medical model and its most limited form is very disempowering for patients because it's all about what the what the the doctor, the therapist does but very little about what the patient can do for themselves and I think that we really need to think a lot more about helping people to be very active participants in their own healthcare to feel much more empowered so that it's a collaboration with their with their health practitioners their GPs their oncologists psychologists their allied health professionals that they're working with so that the person feels like there's a lot that they can do I think that a learned helplessness and hopelessness is something that I certainly strike a lot of among cancer patients that gets reinforced especially when cancer patients say well what else can I do how can I improve my outcome how can I improve my coping and the last things about well what about lifestyle and and what about mental health and its impact on my my well-being and very often I think far too commonly it's more common than not that people are told well none of that really makes any significant difference and some are discouraged from doing it some say oh well you know do it if you want to won't make any difference and it's actually quite uncommon that people are actually encouraged to say well look that's a really important part of your cancer care and I encourage you to get involved with that and hear some support programs that you can get involved with I think we're not doing it well enough yet and I know that a lot on the panel are very conscious about a more holistic approach and I'm sure a lot of listeners are as well and there was a senator an Australian senator a few years ago had a very advanced melanoma and he he asked a lot of these kinds of questions of his health professionals and he got it wasn't that he wasn't helped he was actually felt like he was stone walled in terms of finding further information and accessing further things are outside of the square of what he was being offered in his cancer care and I suppose Meg's an unusual example of a very engaged and motivated patient and I think this senator Cook was a very unusual one as well because when you say something like that to somebody like him he says all right well he doesn't sort of give up what he does as he sets up a center of inquiry which he did some years ago into the into cancer management and there were certainly I think was 32 recommendations but they said a lot of these kinds of self-help self-empowerment aspects of cancer care were being overlooked and there was a need for more information more education for professionals more information for patients more access to support programs so that it's and I think this should be standard not as an optional that it's offered to everybody and that resources are made available and information available to everybody so that's I think and I think the GPs are one of the people who can very much actively help in that area add a lot of value and I think that we're not doing that or not educated to do that I think to satisfaction yet May I just move on just a little bit now because one of our learning objectives is to explore tips and strategies for collaborative care for people with survived cancer and maybe experience depression and or anxiety and Barbara Nettlbeck one of our participants has asked a really good question my experience as a counselor is that some clients are well organized have their own file and accessible knowledge about the history we can facilitate this level of impairment others are disorganized and don't really have a cohesion about their stories so I think what Barbara's talking about is disease versus existential angst how do we cope with that and anxiety and depression which occur in the normal course of life of life does the panel have any anything to say about that It's Phyllis here I might just start by talking a little bit about the existential distress that people experience when they worry about the cancer coming back and I think that sort of anxiety is quite different to some of the anxiety you get as an all as a everyday person who may not have had cancer because it's not illogical you know people do have a some risk of the cancer coming back so cognitive behavior therapy which has been used very widely for anxiety doesn't always work in this instance because that relies on challenging the I guess the sense the sensibleness of those sorts of thoughts but in the for a cancer patient they do really face a risk of cancer occurrence so some of the approaches that we've been exploring recently are what's called meta cognitive approaches where you support people in not challenging their worries their direct thoughts about the cancer coming back but actually challenging the value of worry that because some people feel that if they're not worrying all the time they're leaving themselves vulnerable and they feel that they have to worry that it's important for them to worry and to pay attention to those to that worry whereas you know they may on reflection choose to say to themselves well I'm going to worry for half an hour a day but for the other 23 and a half hours I won't worry because then I can get on with my life and I'll do all the effective worry that I need to do in that half an hour or you know so I guess it's challenging the value of worry and giving empowering them to take control of that anxiety so that it doesn't affect the rest of their lives but David might like to comment on this as well Thanks Alice Yes I'd like to add to that cognitive behavioral therapy often uses the yardstick of what's logical what's rational and in cancer care that doesn't work it's as much more the principle of what's realistic of that I think we try and ask people to examine so that if you get a pain for example if you've been gardening and you've got a good reason for that pain you're able to say it's realistic but my back's a bit sore after gardening and it should go away in a in a day or two and so you can look at the timeline and think well realistically if a pain is persisting over a couple of weeks then I should be back to my GP and having it investigated and so you're putting that realistic emphasis on it as a way of working out how to manage it and how to come to terms with it a common journey for so many cancer patients who's anxiety prior to their next scan their next round of imaging and that's a pretty normal experience but it's important for us to emphasize to them that as they find that their scans are normal as you're saying it's not going to help them to allow that worry to be dominant every time they have to have further imaging and so that's an example I think of your idea of how much does the worry cost you can you put some of that aside can you start to pick a very common sense approach to how you handle any fear over a symptom and keep it very realistic based and I David and Phyllis it's Craig Hussard here and you know I'd just like to endorse what you've been saying and perhaps just add a little bit to that as well I think that that's one of the things about mindfulness based approaches whether it's NBCT or ACT it is a couple of things that are very important it helps to give a person a choice not by fighting with the thoughts that they might be trying not to have all the emotions but to be able to be aware of them and to be moral consciously able to choose to engage with them or to engage with something else and the acceptance bit which is very central in these approaches I think is very important because having a thought or a feeling that we feel that we shouldn't be having but which may be entirely understandable and natural the reactivity to it and the judging of it really totally preoccupies the attention with it and makes it even more intrusive than it would otherwise be and so paradoxically learning to soften the attitude to those emotions and to learn to feel more comfortable in the presence of them helps a person not to feel dominated by them but to learn to live with them to then be less and less affected by them and to engage more and more fully with the life that the person does have to lead and so I think that I'd just like to very much endorse what you're saying before and encourage people to learn the strategies that can help people to do that Thank you very much May I just ask you Meg how the conversation we've been having over the previous five to seven minutes resonates with you as a cancer survivor and as a survivorship centre volunteer Sure I've been reflecting while I've been listening to my fellow panellists talking about how I came to to work around my own anxieties and emotional state as I was going through cancer treatments and various stages of survivorship in between new diagnosis For me I I developed a strategy of dealing with one thing at a time one diagnosis one scan one treatment not trying not to to worry about things that were too far into the future that I couldn't have any impact on to preserve and try and retain my energies by not worrying about the what if and only dealing with what I knew and what I was able to cope with and I suppose that leads me into reflecting on what Craig's been talking about because over the journey what I found helpful was with my first diagnosis I thought help and training in relaxation with my second I stepped it up to to learn about meditation and when I before I had my transplant I found that what I looked for was something that would help me even more and I learned about about self hypnosis so that I was able to actually employ relaxation and mindfulness techniques to help me so the conversation that that has been occurring I understand and identify with exactly and yeah if there was a way to to pass that information on to other cancer patients and survivors that's the journey that I'm on trying to help them and that's what I do in my work with the Cancer Council with their Cancer Connect program I which is a peer support program I speak to other people who are in similar situations to myself and by being able to do that by helping them know that I understand where they are what they're experiencing I understand their 2 a.m. what is that gives them some hope and and some calm as well um yeah that's that's my my sense Michael can I um just add something there and I think that um you know Meg talking about the support she can give to other people is just critical and it's quite clear that um the opportunity to talk to someone else has been through the same experience is so valuable I did want to raise as well though that I think women are a lot better at um asking for support and going for this sort of support than men um and men can quietly suffer or turn to other strategies like alcohol um perhaps more so than than women who are more used to perhaps asking for help and I think that uh we in this modern day and age we've got an opportunity through the web to engage with men in ways that they might not be willing to take up as as a face-to-face interaction with either another person with cancer or with a health professional and there are now increasingly websites for um people going through cancer treatment and also in survivorship who are starting to try and deliver these sorts of skills and uh give people education and support around how to manage their fears of the cancer coming back and other issues in survivorship and I think we'll see more of those in the years to come but I think the issues for men are perhaps require a different approach I don't know what whether other people would like to comment on that oh yeah could I just have a quick comment from Marco Jefford because time has flown by and we have a very short time left so Marco just just a mad minute on men versus versus women responses to therapy approaches I'm going to be I'm going to be a politician and take the opportunity to speak about something else I think I just want to I want to follow on from what Phyllis has just said I would have done it a little bit more skillfully but but I think that what Phyllis has highlighted though is the need to harness as much support and as many resources as possible so you know that might be through support groups that might be through peer support that Meg's talked about like the cancer connect program sorry it's it's Michael Jefford talking sorry the webinar people so and I think that we're not going to be able to provide comprehensive care to cancer survivors without harnessing all of these different strategies and Craig's talked about the sorts of things that people can do for themselves as individuals and Phyllis has talked about the need to be able to connect with people as has Meg and that might be but it also talks about the need to to think about accessing people through through people on accessing people online but also using other resources which might be cancer councils I noticed in the chat area people were talking about carers carers Victoria and other state equivalents but trying to harness as much support as we can ideally not in a just a complete fragmented hit and miss way because what we're trying to do is to do this in a much more systematic way that identifies that some people don't need that sort of support but other people do and trying to tailor this so that we can identify individual issues needs predicted problems and then anticipate those things and tailor a program of support for that person thank you oh I didn't I didn't answer the question about men versus women no that's fine maybe you should become a politician now we're just coming towards the end of tonight's webinar I'm going to ask each panelist to sum up in two minutes to reflect on some of I'm actually going to go in a reverse order from from how we started I'm going to ask you David to to sum up first in two minutes please thanks very much Michael yes I think empowering our patients is a very important philosophical stance for clinicians to adopt and to recognize the process of tailoring what we work out to meet their needs we've heard Craig emphasize the benefits of mindfulness-based cognitive therapy stress reduction therapy acceptance and commitment therapy has been talked about people have mentioned narrative therapies meaning-centered therapies cognitive behavioral therapy it's from my perspective a clinician's responsibility to try and identify what is going to suit the individual patient and tailor the selection of the model of therapy to respond to their needs that's part of the clinical art of working out what is going to be the most helpful approach to support a person and to connect them to community supports and to ensure that they're well educated and empowered therefore to adapt and to cope with their survivorship period thanks Michael thank you very much David and now Phyllis in two minutes may I ask you to sum up well I suppose what I'd like to end up with is just to comment on the importance of this area for all of us and the need for all of us to advocate for improved supportive care services and certainly people like Meg and other people who have survived cancer are in a very powerful position to advocate for these things as well as health professionals and it's only through that sort of advocacy that we can get system change that really incorporates supportive care into cancer you know into holistic cancer care and I think that's just critical so I'd just like to put in the last plug for us to all think about how we can really bring this out into prominence thank you thank you very much Phyllis and Craig in two minutes may I ask you to sum up please yes there are a few points that I'd just like to making closing this continuity from hospital to community and to have that resource so that people can provide the kinds of services that we've been speaking of just secondly in terms of these kinds of more holistic approach these sorts of things can only have be offered that can't be imposed on people and so I think through informing and gently working with the person's motivation their interest that the approach is individualized for that person and it's not one size that fits all but it's a flexible healthcare system and practitioners that can help adapt all of the possibilities that could be available for that person in a way that's meaningful for them one of the things that I hope is that we never put people in a difficult situation through some kind of turf war that people are being asked to either choose what's seen as a conventional healthcare approach or maybe some kind of integrated approach that's seen as being alternative for me it's not about anything that's alternative it's about making our conventional healthcare more holistic and making sure that any kind of things that are outside of the usual care are evidence based and supported but that we move towards not two different systems and people have to choose but one integrated system that helps individuals very briefly the last thing I'd say as well is that I I do believe obviously being passionate about mindfulness that mindfulness is as important for the therapist as it is for the patient firstly so that we can be more mindful in the consultation and listen better and more openly to our patients and engage them better but also so that we care for ourselves and we help to prevent care of fatigue or care of burnout particularly when we're working in areas like cancer or mental health where those kinds of issues can be very real for the the carer so we need to care for patients and that includes caring for ourselves so we can turn up for them and be present with our patients every day thank you very much Greg very good points and Michael may I ask you to sum up sure not so much summing up I'd agree with everything that people have said before and unfortunately it's harder when you have to go towards the end then you get to say well everyone said what I was going to say but I had noticed that in the I would like to I mean Meg works with us at the survivorship center and works as hard as everybody else who just do the only differences if you don't pay her but in the general chat room we we heard a lot about how important is to hear the voice of consumers and survivors and I think that Meg has been able to the share her experience and highlight the sorts of issues that survivors can experience the fact that the the path isn't clear that that it's very fragmented very hit and miss and I guess that that highlights to us that we've got a way to go she highlighted the need to listen but also to ask and I think that sometimes it can feel overwhelming to think well how do we provide this care when there is a big gap and it will take some time and Phillips talks about the need for system change system level change and I absolutely agree with that I think though that there are things that we can do right now and it is surprisingly as a clinician not a psych oncology professional but it is surprisingly helpful to be able to provide people with information to put them in touch with other people who've been in a similar situation to normalize the sorts of experiences that people encounter in the post-treatment phase that to me it seems it's one of the nice things that it seems like a useful intervention but it's so simple and it struck me for the whole of my career that why don't people provide patients and survivors with information or link them to free services in the community so I think that there would be some of the things that we can do right now I would absolutely agree with what Craig was saying about we know the benefit of exercise for survivors is absolutely there's no doubt that exercise has broad ranging benefits including in a number of studies reducing the chance of cancer coming back so we have to find a way to promote exercise as a really important intervention I thought I had nothing to say and now I'm going on forever I'd also talk about this has been an exercise I think for all of us including myself in sort of awareness raising and thinking about the issues and as Phil has suggested we do need to continue to raise the awareness of importance of supportive care but also the importance of more holistic care not just during the treatment phase but in the post-treatment phase and I guess that I would highlight that again something that we can do as of tomorrow is to be more aware and also to start thinking about what sort of screening tools can we use even if it's if we decide that it's going to be asking about how are you feeling and something simple and then we might think about well whether we could incorporate a screening tool there's a source of things I think we can do as of tomorrow they're just a few points thank you very very much Meg we'll we'll we'll let you sum up last okay I suppose what I want to say is we've all talked around many issues tonight for me next steps are important how these issues are going to be translated into action my story highlights the fact that while after so many years some things have changed many remain the same and survivors are often left to find their own way and to advocate for themselves I'm grateful that opportunities such as tonight's webinar are created to bring together so many professionals who interested in and who are working towards improving the well-being of the increasing number of cancer survivors in our community and to finish I am indeed lucky to have found my voice to help smooth the roller coast to ride for other survivors and I'm grateful to have been able to be part of tonight's discussion thanks Michael thanks very much Meg and you know those great blows we are to have you here tonight I can't see you I am now I normally when I'm when I'm summing up I normally just have a few depots but I have an A4 and a half page here of points which I probably won't get through but I'm just going to give you some stand by from what I hear tonight survivorship care plan the psychological element we need to be working with evidence we need to be having surveillance both medical and psychosocial we need to have good coordination we need to have continuity we need to remember about spirituality and mindfulness we need to have to make integrated care normal care that should be the norm the existential issues the value of worry and these how the system sometimes fails us the physical effects the psychological distress and the and also the use of of of that I wasn't aware of I normally use that an electronic moment or now but that distress the moment I and it seems to me very usual and I'll certainly be googling that tomorrow and I I was particularly taken by the concepts of worry and and mindfulness and lastly may I say that one thing that came through from everybody's talk was asked the patient and there's an old saying in general practice that there's more myths from not looking than from not knowing and I think there's more myths from not listed from not asking than from not knowing so they are the elements that that came to me well well said Michael so I but so I've had computer problems all day and I'm unable to see anything in finishing I would like to thank everybody for their participation from the bottom of my heart and I'm sure from the bottom of all our hearts because everybody's involved in this tonight both participants and presenters stand as if they have heart which is which is very important in caring for people and I I accept Craig's comment about care of fatigue as well and can you please make sure that you fill in any of your responses that should be filled in for MHBN I cannot see anything online at the moment it is now 8.13 so we have approximately one minute left the other points that I heard tonight were the importance of of looking at people who are survivors is also developing other illnesses not both from their treatment and also from from from the normal course of their life and that they shouldn't really be treated any differently from other patients I would like to thank everybody from the bottom of my heart for attending tonight I'm sorry I'm unable to see any of the remaining slides please contact MHPN and please fill out your evaluation at the end of the webinar and on behalf of MHPN and everybody involved in this field on behalf of the participants I would like to thank the panel very very much for the expertise and presentation tonight so that will bring this webinar to a close thank you everybody everybody for attending thank you Michael thank you