Ep2: Where research transforms cancer treatment

Host and Producer

• Dr Rosie Anderson, Research Fellow, Public Health Policy team, UCL

Guests

• Marcelle Bernstein, diagnosed with breast cancer in 2012
• Dr Sandeep Nayak, Fortis Hospital, Bangalore, India
• Dr Samuele Massarut, CRO Aviano, Italy
• Professor Jayant Vaidya, Division of Surgery and Interventional Science, UCL

Transcript

Rosie Anderson  0:08   

Hello and welcome or welcome back to the podcast where research transforms lives. I'm Dr. Rosie Anderson and every Thursday this summer, I'm inviting you to take a deep dive with me into the UCL research that has changed the world around you. This episode is the second in a double bill that looks at how medical research has transformed the health, wellbeing and dignity of millions of people around the world. Now, lots of university research comes from trying to solve a particular real life problem. The thing is what seems like a tiny problem often turns out to be connected to all sorts of other problems, solve it, and you start changing the world around it. This episode I'm talking with Professor Jayant Vaidya of the division of surgery at UCL is innovative radiotherapy device called Target has revolutionised the way we treat breast cancer. Traditional treatment is surgery to remove the cancer followed by weeks or months of emotionally and physically draining radio or chemotherapy. This exposes the patients to new dangers, flooding their bodies with toxic chemicals or radiation. And as a young surgeon in India Jayant saw how devastating or even impossible the constant trips to hospital were for the women he treated. I sat down with Jayant and his colleagues Samuele Massarut of the CRO in Aviano Italy, and Sandeep Nayak, Director of Surgical Oncology at Fortis hospital Bangalore, to tell me the story of how a young surgeon in Mumbai set out to make a radiotherapy device that would make his patients lives a little easier, and wound up discovering new things about how the body heals, transforming breast cancer surgery, and taking on the economics of health care around the world. I also spoke with Marcelle who was diagnosed with breast cancer in 2012, and treated us and target and it's her story we'll start with 

  

Marcelle Bernstein  2:01   

Hello, my name is Marcel Bernstein. I'm a journalist and an author and lecturer at City University. And almost 10 years ago now I was diagnosed with breast cancer. And I had a most interesting experience and I'd like to share it with you. I'd had a mammogram, a routine one, I think they come to an end I was at that point, I was 68. I had no burst pain, I'd had no problems. I'd had no hints, no lumps, no bumps, nothing. So I just expected the usual letter. Dear Mrs. Clark, please don't worry or your phone. Instead, I got a telephone call from the hospital at major London teaching hospital asking me to go in for an urgent biopsy. So I knew I was in trouble. The stories that were going through my head are not stories anybody would want 15 years or so before that my mother had died of breast cancer. So I knew all too much about it. Back in those days, nobody talked about it. My mother Least of all, you didn't discuss these things. I mean, thank God now it's so much more open. But I remember very vividly that what happened with my mother when she knew that she had breast cancer from all the things like the inverted nipple, things like that she wasn't a fool. She hid it from herself. And she would get up every morning and say to a very sternly No, no. And she behaved in general, like an old Jewish woman in a shtetl somewhere in Russia, who had no option. We watched her die. And I was determined that ever anything like that happened to me because I'm an Ashkenazi Jew, and therefore you worry about the genetic side of it. I would treat it very differently. So I think from the off, I had a very positive attitude. There were things I could do, and I was done. We're going to do them. 

  

Rosie Anderson  3:56   

Welcome, everybody. Welcome, gentlemen. Thank you. Thank you. Thank you. Thank you, and Jayant. I just want to start by talking about how you came to want to work around radiotherapy and breast cancer specifically, and where did this journey start for you? 

  

Jayant Vaidya  4:15   

Well, it started more than more than 20 years ago, when I was a chief resident, and then surgical and research fellow in Tata Memorial Hospital in Mumbai. At that time, patients used to come from all over India, for treatment of cancer to this premier Cancer Institute. And as residents, we would have to give them the diagnosis and then plan their treatments and then do the operations. So for breast cancer, we would the it was well established that mastectomy and breast conservation are similar in outcome and patients would prefer breast conservation surgery, but that comes as a package. That means if we do a lumpectomy or wide local excision and preserve the breast, it would need to be followed up by radiotherapy. And traditionally, radiotherapy is given as a course of six weeks, five to six weeks, or three to six weeks now. And this is done through daily treatments, where the individual daily dose is small enough for the breast to tolerate. And, and enough to kill cancer on a regular basis, from Monday to Friday, for three to six weeks, and these patients from from all over India would have to come and stay in Mumbai for those six weeks, in order to take the radiotherapy. And unless they agree to do that, we wouldn't be able to consider the breast because in that case, without the radiotherapy, it would be inadequate treatment. So it was not nice for me to tell this lady who is now facing the diagnosis of breast cancer. Can you stay in Bombay for six weeks after the operation? Or two months? And if she can't, we would have to say we have to do mastectomy. And this was happening in every case. So that was the situation in the clinic.  

  

Rosie Anderson  6:08   

I just want to bring in Samuele and also Sandeep and ask them does that tally with your experience as well as clinicians, as practitioners, were using similar patterns in you know, in Italy, in your own practice in India. 

  

Sandeep Nayak  6:24   

there is there was a segment of you know, those patients who wouldn't want to come so often to hospital, especially the older age groups, you know, people above 70, though, they would want to save their breasts, but they wouldn't want to come so often every day for three weeks to six weeks. 

  

Samuele Massarut  6:44   

In Italy, there are plenty of centre of radiation therapy centres. So it's not as these times is not an issue. But nevertheless, you know, six weeks every day, maybe you have children or you know, you have to go to work and it's difficult to a radiation Therapy Centre for an hour or two even though the treatment lasts two minutes, more or less. But you have to drive there and then wait. Yeah, so it's not it was not so easy.  

  

Jayant Vaidya  7:27   

The other places which have had problems and faced a situation similar to what I faced was in Australia, where patients came back from outbacks, where they wanted to go back. It happens in in Denmark, where people don't want to leave their island, it's fifth several 100 islands, they want to stay in the island. They want to come to the Copenhagen and have a treatment, they would rather have a mastectomy. It happens in places in the UK, because there are many places away from the centres. And even UCS in San Francisco, where if they're on this side of the Bay Bridge, they're happy to have a radiotherapy. But if they if they are treated in County Hospital on the other side of the Bay Bridge, they don't want to cross the Bay Bridge every day for six weeks because they lose their jobs they the whole day. Simultaneously, I was working to see why are we doing? The question was in my mind, why are we doing this? Why are we treating the whole breast? When we can do a lumpectomy, we moved from a radical mastectomy or lumpectomy why are we still treating the whole breast? And answer to that appeared to be because the dogma was that there are multiple other cancers in the breast. So I did a laboratory study, I found that two thirds of these patients had other cancers which were previously unidentified in their breasts. And we would have thought we could do a lumpectomy in them. And I the new thing we did was we plotted these in three dimensions in each breast. And I found that these other cancers are spread all over the breast. But we knew from long term outcomes of patients who had lumpectomy with or without radiotherapy, whenever they get a recurrence, it would happen around the tumour. These other cancers which are sitting there are biologically not the same as the main tumour and do not grow in real life. So this was in 1995, presented in Hong Kong and published it in British Journal of Cancer. 

  

Marcelle Bernstein  9:22   

Wait, although I'm saying I was positive about it, because I was terrified. Because maybe it's a death sentence you absolutely don't know at that stage. So the first thing that happened was, I went to a consultation with a man who I later learned later, was a locum breast surgeon. And it was not a good interview from the start because he sat the body language was bad. He sat half turned away from me so that I got a view of him looking at me over his shoulder, which you can probably imagine was him being negative About me, I don't know. He told me the important things he told me about the size, he told me it was great one, he told me that I would have to have surgery, I took my husband with me because the one thing you should always do is take someone with you to a meeting like this. And we also asked him if it was okay if we recorded it. So he knew we were recording this purpose of this discussion. And one of the first things he said to me when he heard my origins was, you should have a mastectomy, said it right at the beginning right off. He then as we talked and said, Maybe I should have a double mastectomy. And this was my first meeting, my first discussion about this. And there was a mother's breast care nurse with us sitting opposite me. And I could see the look of horror on her face. This was before I should say that I had any kind of genetic counselling. So we really we were floating in waters that neither the breast surgeon or I knew anything about. But as I left, he called after me, can I book you in for the big one. So my husband and I walked out, and we looked at each other, and we said, Oh, my God, we need a second opinion. I'd actually said to the local breast surgeon, which was probably a mistake, I said, Look, I love my, I love my breasts, but I love life more. So if I have to have a double mastectomy, then I have to, nevertheless, it would have been, it would have been a horrendous thing to face, even at the end of my sexual life, really, because as I said, it was approaching 70. It would have been a horrendous thing, both for me and my husband. It's an amputation. It's a loss. I do believe, I do believe in treating your body gently. And this is possibly the harshest thing to do. I remember talking to an elderly breast care nurse. And she said that she could remember treating women who'd had massive what they call heroic surgery, when an enormous amount of muscle was taken as well. And she said she could remember that women were unable to move their arms, that truly after having mastectomies. So it's people have been treated, very brutally, women have been treated very broadly by the medical profession, in terms of Breast Care for decades.  

  

Rosie Anderson  12:27   

Do you think the fact that these are breasts, and these are women was an element in that as well, that that that brutality that many?  

  

Marcelle Bernstein  12:35   

I think that is I think you've actually put your finger on it. And I do believe that, but it's not something I say very often because it's it, it sounds sexist. I, if men had had breasts, they would not have been treated this way. If we were talking about men's testicles, they will be treated very differently. It's, I think there was a feeling, don't you that breasts are a sort of people look at them, they look at your breasts, they maybe enjoy them. It's a sort of slightly, it's a paternalistic attitude, which at that time, we were a much more paternalistic society that you're you looked at as an object. And the other thing, of course, is that if you have entire breast radiotherapy, chemotherapy, whatever you have, you need, you have to remember that even with radiotherapy, which is the milder form, it's still brutal for the body. years afterwards, your heart can be affected, lungs can be affected. It does affect the organs that it touches. If you have delicate skin, if perhaps you're a redhead, that radiotherapy is is punitive to your skin. You can get the hardening of the breast, none of these things matter if you're treating major breast cancer, and then they are the risks that go with the benefits of the treatment. But if you don't have to have them if they can be avoided, that avoid them, and targeted for into a large degree avoids all those. 

  

Jayant Vaidya  14:09   

They met Professor Michael Bohm, and Professor Tobias when I came to London the first time and said, well actually, you know, this is a paradoxical situation. We have this multicentric, we should treat only the area around the tumour. Yeah, with radiotherapy. And just serendipitously I was there at the right time at the right place. They were talking to this photoelectron corporation who had acquired this device where they wanted to see how they can use it, and it wasn't being nothing was done. So we developed applicators for it to be used in the breast and say Okay, with this device, not only will we give it only around the tumour, but we will do it during the operation itself. So we do it at the right place, without any delay without missing a target. The next step after we knew it was safe to do we were worried about what infections were, but it didn't have a problem, apart from a third patient, we knew exactly how to do it by the end of that time, okay, let us do a randomised trial. And we published a protocol in the Lancet to say we want to randomise patients randomly allocate to receive just this treatment in the operation theatre or usual six weeks, five to six weeks of whole breast radiotherapy. That's what started in 2000. It was lucky or fortunate that we were able to do a randomised clinical trial, which is the highest level of evidence in which so many people from around the world participated. So it is more generalizable. And the bonus really, and the bonus is actually even better than what we started out for. We started out for a better convenient treatment, more convenient treatment, which might be less toxic, but what we found was there are fewer deaths, giving this treatment means we avoid over treatment and toxicity of radiotherapy which is unavoidable with even with the best techniques. So we have found that there is a fewer deaths from other causes, which leads to improvement in overall survival, which is not dissimilar from what one gets with treatments, such as Herceptin, which goes on for a year are very expensive. 

  

Marcelle Bernstein  16:19   

Because as I said, I knew about my mother. After her death, I became much more aware of things we could have done, but didn't know to do which, as the guilt is bad, but what can you do? Hindsight is a wonderful thing. And I had been of course, I read the papers. I'm a journalist, and I was very aware of Professor Michael Baum, who is a leading Breast Care surgical oncologist in this country. And he was writing a lot at that time he was he was a pioneer of lumpectomies and radiotherapy. And I've been reading what he said and I've always said to myself, is this happened to me go to Michael bomb. So I emailed him. I was I was told that he had retired now semi retired, but I emailed him anyway. A few hours later, I got a phone call from an associate of his Mr Jayant Vaidya. who subsequently came my breast surgeon so he phoned me just within hours 

  

Rosie Anderson  17:21   

Going through something like a cancer diagnosis and then treatments therapy. In it, there's the the immediate diagnosis of that disease or something specific which is going on in your body. But then there's a whole life around that body isn't there is an experience of being a patient, family, and family. Indeed, there's a whole family around that person.  

  

Sandeep Nayak  17:45   

Caregiver is very often the one who's earning for the family, or has some other responsibility as well. So when they when this patient has to come, the caregivers, you know, daily routine gets disrupted. So often an elderly patient would be more concerned about that, rather than, you know, saving her own breast and I think this would be a good option if they want to save their breast. I see that happening today in my practice, though, we have just done about I think six to seven cases so far.  

  

Jayant Vaidya  18:23   

Hearing that gives me goosebumps 

  

Marcelle Bernstein  18:29   

Mr. Vaidya told me about target, I went to see him. So I wasn't part of the trial, they'd had a 12 year trial for target. And it was just coming to an end so they didn't need any more people. So I got it through private health care. But of course now, brilliantly, it's available on the National Health. When I knew from Jayant that I was not going to have to have anything like a mastectomy, that in fact, it was going to be a lumpectomy, that it was going to be a small incision. It was a one day treatment, which of course what makes target so marvellous, especially in these days of COVID and anxiety and cutbacks you're in and out, you're not going there day after day for radiotherapy, which takes a few minutes, but you have to get there you have to wait you have to have the treatment you have to come out you have to get back. So So car miles waiting time travel expenses, there is none of that. 

  

Rosie Anderson  19:34   

So I would love at this point to ask you a question that I may regret, which is to try and explain how exactly how exactly this works. First of all, what does target stand for? Start with that. 

  

Jayant Vaidya  19:48   

So that is a favourite question of mine, because I coined the word while coming back home in a train, so target is targeted intraoperative radiotherapy and it's a sort of targeting the cancer. So that's why I called it target. And that sort of stuff, how it works that I can answer in two ways. One is what is the physics and second is the radiobiology.  

  

Rosie Anderson  20:17   

Okay, whichever is kindest to my brain, 

  

Jayant Vaidya  20:21   

I hope I can make it make it make it simple. Okay. So the physics is such that in the box, it's like a mini Linac mini linear accelerator where electrons are generated the accelerator along a thin tube, and the hit the tip of this tube, and the tube is about six centimetres in size, six inches in size. 

  

Marcelle Bernstein  20:47   

I explained it all to me as a small incision, they insert this the intravenous, which is an instrument with a small ball on the end, which is sized to fit the where they remove the tumour, so it's an exact fit, they put it into your breast, they sew it in.  

  

Jayant Vaidya  21:10   

you make applicators which are like small spheres, which go around this tape, and we choose the size of this applicator depending on how big the tumour was. So now imagine this electrons, when you switch on the machine, electrons move along this tube hit the goal and radiate X rays.  

  

Marcelle Bernstein  21:28   

this little gold centre to this to this sphere. They aim X ray rays at it, the gold bounces the X rays back off into the surrounding tumour area. So it's only affects that tiny area of your body.  

  

Jayant Vaidya  21:47   

These X rays are modulated by the spherical applicators so that you get uniform dose of radiation at the surface of this applicator, which is the tumour bed, which is the site of the highest risk of recurrence. And the dose reduces quickly as you go further away into the breast and the body. Right so that beyond a centimetre or two, there is not hardly any dose, so by the time it reaches the heart or the lung, it don't have any any radiation that can be damaging, so it only radiates immediately around the tumour. And what it does, in terms of radiobiology is two things. This dose is high enough to kill any tumour cells that might have been present in the tumour bed. In addition, it seems to have an effect on the normal cells around it. And this is some work which Dr. Masaru Tez. And is Dr. Baldessari his colleagues have pioneered in which it seems to be that the phenomenon that occurs normally after surger. After surgery as per our evolution of 1000s and hundreds of 1000s of years, we didn't have operations when we were bit by a tiger. And we survived that wound healed, right. So any wound heals at the time of healing, our body has learned to create an environment which is fantastic for growing and healing. And this environment is what we create when we do an operation. If there are any cells in the body, which are circulating or cells left there, it is a fantastic environment for cancer to grow, multiply and move around. This was studied by looking at the fluid that collects in the wound. And when that fluid is looked at, we find that it does stimulate cancer cells, right. But if you take away the fluid, after someone has had target, it doesn't do that. There is also an effect on the microenvironment of the cancer. 

  

Marcelle Bernstein  23:45   

In the end, it turned out that after after surgery, it took some time, because I can now not find where the scar is I can't there's no mark on my breast at all. Apart from the usual creases you get at the side of your breast mine was sort of under the arm. So it's it's wonderful, both from the the physical aspects of how it treats you. But also from the mental and emotional aspect. It is tailoring medicine for the individual, which is the future. It's not a one size fits all. It is something that that your specialists will look at you and say, This is what we're going to do for you this, this and this. And it's as it's as tight and as controlled as possible. 

  

Sandeep Nayak  24:31   

It has indeed opened the doors to investigation on how radiotherapy actually works. So and this is one of the reasons why people find their foundations of how radiotherapy works a bit shaken because of the data that was produced as part of the target studies.  

  

Rosie Anderson  24:46   

Yeah, I think a lot of people think that scientific inquiry is always extremely predictable and quite tidy. And I think this is a really interesting example of how actually there's lots of serendipity. There's lots of exploration. That's adventurous, right? Yeah, absolutely. 

  

Sandeep Nayak  25:08   

It is. That's what gives it the rest of the Act really to do it. Because despite a lot of opposition people calling you mad. That's literally what happened. We were called this mad people. 

  

Rosie Anderson  25:28   

Why, what why? Why did people think that this was so crazy, then why was this?  

  

Sandeep Nayak  25:33   

One of the reasons. Well, let me see what I, what I see. Yeah, I think it was because the dose which we gave, a physical dose of radiation is small, and we are going and interfering with an operation. And we could cause harm, because it will not heal. There were a lot of concerns which people had, which we that's why we did it slowly. We started one by one one by one. And because the price if it worked, the vision was that if it worked, it would make a big difference. Yeah, and it was, we were recruiting for the first four years, very few patients in the trial. And that's where they came in. And Australia came in and Germany came in, and then it went up. 

  

Rosie Anderson  26:23   

I'm interested, actually, I'm sure quite a lot of listeners would be about how important it is to have an international trial. From small beginnings, this became big, in fact, and, and yes, involving several centres right across the world.  

  

Sandeep Nayak  26:39   

What we were testing is what will happen in the real world if this was introduced in practice. So the surgeon, we didn't have a very prescriptive method of doing an operation, we had to the surgeons would need to conceptually understand that this is what we want to give. And then it was left to individual surgeons to do the correct operation to give the correct radiation oncologist give the correct treatment and and in radiation oncology to decide whether they need more radiotherapy afterwards, people had different multiple teams. So it is generalizable. Every geography plays a different, you know, a place in a different way. That's what I observed when I see various geographies. And India is a completely different ballgame. You know, we have exceptionally good technology adoption here. But I have not seen a we don't have a single functional intraoperative radiotherapy machine in India, except this one, which I'm running right now. So technology adoption, when it happens, you know, it has to be spearheaded by somebody. So, you know, every time any new technology comes into medicine, it is always rejected. Nobody accepts it. 

  

Rosie Anderson  27:53   

I'm really struck as you talk, Marcelle, that you keep using the word brutal. You keep using the word brutality. And we've, how we talk about health and bodies and illness and disease. Frames how we as a society, think about it, think what's acceptable, frame those risks even and, and I'm really struck by how, how we keep coming back to this, where you might expect to hear care, yes, you hear brutality, in your, in your words.  

  

Marcelle Bernstein  28:30   

you see it in obits in the papers, don't you battling cancer, losing the battle with cancer, struggling against fighting, that they're more than words, whereas this is your body, you want it treated gently, and I'm reluctant to go on about it too much. Because if you need these things, then of course, those results are secondary to the important fact that they're curing you. But nonetheless, if you can get away with it, then you should get away with it. And this target is the gentler option and it's, it's kinder to women, it is  

  

Rosie Anderson  29:07   

I suppose what we're both saying is the way we frame what it means to be ill and what it means to quote unquote, fight it sort of frames what's acceptable as the price that you pay as well. And then even the need, you know, even the need to make things kinda won't be as visible perhaps if we if we talk about it in those terms. In terms of target, first of all, from Jayant and then I really want to know about you Samuele that and, and also Sandeep, but in your different contexts, what it took to go from having this new and new invention, basically, with all of these fascinating and brilliant outcomes out to patients.  

  

Jayant Vaidya  29:49   

so people felt that the patients, clearly patients would love it, and if it's practically possible for me to do it, without causing too much disruption to the hospital, then we should do it. This is something that improves quality of life reduces pain. For patients, it's convenient, it is least disruptive of treatments. But in some healthcare situations, it can be the most disruptive to the flow of patients in the radiotherapy department. A third of regulatory departments patients are breast cancer in the Western world. So if somebody sits back and thinks, Oh, this looks nice and beautiful, but a third of our patients will never come to us. That can make people stop. And I have never said this before. But it was published by the chief editor of the red Journal, the top radiotherapy journal, who described it as target can be considered as a quantum leap forward, or a significant threat. So this is what is published. Yes, it's published this. And if radiotherapy, remuneration to the hospital comes from number of times the patient comes to the hospital, or every time is 200 pounds, then more number of times, they come better it is. And nobody will pay somebody as much as what it would be. If it is done at the same time time during the operation, if you count it by the actions, if activity based payments, it doesn't work. But if it is value based payment, it works. And Sandeep has found a very nice model in his hospital where everybody pays the same whatever treatment they get. And a whole team gets it. If I say it correctly, if I understood it correctly, then there is no disincentive to give the correct treatment. I thought that would be the case in the NHS, but NHS hospitals have become corporate bodies. So it's tricky. 

  

Rosie Anderson  31:39   

It's just how to make it work in is the health systems  

  

Sandeep Nayak  31:44   

see, you know, as doctors, we are not financial and management trained very well. That is our biggest issue. So that's where I thought, you know, when I have to see this go through and grow, I need to involve everybody, all these stakeholders. So the financial model covers the entire team, so all payouts go from this team revenue. At the same time, you know, I have to look after the hospital's revenue as well, you know, I'm working in a private hospital. So if it reduces hospital's revenue, they would also be bothered, it's a patient, we are doing it for the benefit of the patient. But if hospital sees it as a loss, then they may not promote this particular instrument or equipment. So I took a decision that, you know, if, if it has to succeed, then the the hospital's financial gain should be almost parallel to what it would earn when it is, you know, involved in EBRT. So that's what I have done, I the packages actually run parallel, the financially is almost the same whether the patient gets an EBRT, or IoRT, the the the hospital case, the same At present, we need to only think about the patient's benefit. That is the only criteria which has to be seen here. 

  

Rosie Anderson  33:19   

Jayant already mentioned in the NHS, you know, which is obviously a public health system, you know, it's still very much by activity, it's it and to think about it as benefit is quite a mental shift. I would have thought, but it is.  

  

Jayant Vaidya  33:33   

And I was so pleased to see how Sandeep has done this.  

  

Rosie Anderson  33:37   

Yeah. It's really interesting and something to someone to watch, maybe we can learn from  

  

Jayant Vaidya  33:42   

and replicate. Yes. 

  

Marcelle Bernstein  33:46   

And I'm now on the steering committee. I'm really excited about this, for target for much younger women, up to now that 12 year trial that was taking place was for older women. Now we're trialling it for much younger women. And you can, you can absolutely argue that for much younger women, it is much more important. If you've got children, small children, a career, a busy home life, possibly older parents to look after, look, what women do undertake, then for you to be treated quickly and easily is beyond measure. 

  

Jayant Vaidya  34:26   

Target B is for those patients who would not have been otherwise eligible. So now we know that for 45 years and older, if it's invasive ductal carcinoma, up to three and a half centimetres, they can have target a as standard of care. But if they have got lobular cancers, more than one cancer if they have received neoadjuvant chemotherapy before the operation, and if they under forty five, they would not have participated in target a trial. So we don't know whether it works for them or not. We also found out in a separate study, that when you give target IoT plus external beam, it seems to have a lower local recurrence rate. So we started the target B trial back in 2013. And it has recruited now nearly 1800 patients is 2000 patients we want to recruit about. So 200 more to left half the patients would get it during the operation. halfword did it postoperatively. But most of these patients would get chemotherapy as well.  

  

Rosie Anderson  35:23   

We have not yet seen the last chapter in the target. The target story then, yes. Well, I wish you all the very, very best with everything that you're you're doing. And thank you so much for talking to me today. It's been a real pleasure. It's been so interesting.  

  

Jayant Vaidya  35:42   

Thank you very much. I must not forget to acknowledge all the investigators and patients and the teams with the the writing committee being with along with me, Professor Michael Baume, Professor Jeffrey Tobias, and some experts era.  

  

Rosie Anderson  36:00   

That's all for now. I hope to see you next time where I will be talking to Professor Elizabeth Shepard and John George Nicholson, about how young people in care can have a voice in the records that are made about their childhood. If you can't wait until then and want to hear more about the impact of UCL research on society in the world, then why not take a listen to Made at UCL presented and produced by our students. Finally, I want to thank Jayant, Samuele and Sandeep, our guests, and of course you our listeners. 

  

Unknown Speaker  36:33   

This podcast is brought to you by UCL minds, bringing together UCL knowledge, insight and expertise through events, digital content and activities that are open to everyone. 

 

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