Sorry, hopefully everyone can see the slides there. Yeah, they're not in presentation mode, but yeah, there we go now. Perfect. So our case this evening, I suppose builds on the work that was done at the nursing symposium at the IGCS meeting for anyone who was there. We had an excellent talk on immunotherapy toxicity, and it's something that we wanted to try and bring to potentially a wider audience here with our echo. So this case study involves a 43-year-old patient who is para zero and had a screening detected cervical cancer diagnosed. In Ireland, we have a very high profile national screening program. It is invitation based and run by our GPs or primary care physicians where anyone with a cervix who's aged between 25 and 65 can avail of a HPV smear. So this patient had attended her general practitioner or family care physician, and she had missed her smear. It was a couple of years out of date and an abnormality was detected. There was an H cell seen on that smear. She was referred into the colposcopy department and underwent a pretty large let's biopsy for an abnormality that was seen at the time of colposcopy. The histology from that showed an invasive, moderately differentiated squamous cell cancer with extensive lymphovascular space invasion and the margins of the let's were positive. And the immunohistochemistry showed that this was a PDL1 positive cervix cancer. And the patient was immediately enrolled in the gyne oncology pathway where staging MRI pelvis was organized for her. The tumor was identified on the MRI, but there was no apparent parametrial uterine body or vaginal involvement. However, there was a 1.3 centimeter suspicious node on the right iliac chain, and the patient went on then to have a PET-CT scan. So again, the PET-CT did locate the primary tumor and felt it was localized to the cervix. But there was more extensive lymphadenopathy identified on the PET-CT, which really shows the value in doing these scans. And then surprisingly enough, there was also, as well as the iliac lymphadenopathy up as far as the aortic cable nodes, there was a superclavicular node identified, which was really unexpected finding. And so we went through all of the questions, had the patient had a recent vaccine, anything that would indicate that there might be another cause for a superclav node to be lighting up on PET. But an ultrasound guided biopsy of the node showed that it was positive for disease. So the patient went through our tumor board meeting and she was, her final stage was a stage 4A squamous cell cancer of the cervix. And her recommendation for treatment was induction chemotherapy plus pembrolizumab followed by concurrent chemo radiation and to continue the pembrolizumab for two years as per the keynote 826 trial. So at 43, the patient was obviously really keen to start her treatment and she completed the induction chemotherapy and the chemotherapy radiotherapy with no significant toxicity or treatment delay. Again, she had no other comorbidities. She was young, fit, well, healthy individual and tolerated the treatment well. She did become menopausal and quite quickly when starting chemotherapy. And she did start HRT while on treatment, as per the recent British Gynae Cancer Society and British Menopausal Society guidelines, which were released last summer. So the patient had a busy first year between the different treatment modalities. But one year on into her pembrolizumab, she started to complain of joint issues. So this was mainly affecting her. It started mainly affecting her shoulders. She found she was unable to lift or carry items such as her grocery shop. It was worse in the early mornings. She was very, very stiff getting out of bed and it was preventing her from completing her usual activities. And these were things like shopping and activities of daily living, but also her exercise. She was a keen swimmer. The pain progressed from the shoulders down to her hips and feet also, and there was no associated joint swelling and there was no skin rashes or skin changes. So what are we'd like to have a discussion now, I suppose, around this case and really focus in on the patient's symptom profile and remembering that she's 43, she's in a treatment induced menopause and talk about how you might assess this patient across the various different clinical settings. And I think Anne and Chrissy are going to maybe lead on the discussion. So I'll just stop sharing this for a moment. If you want to start and then I'll piggyback. Sorry, take myself off mute. Yeah, so just sort of wanted to talk to people about what were their first thoughts around those symptoms. I mean, the first thing that I thought was, you know, are these symptoms necessarily related to her treatment or are they menopause related symptoms? And what would you do to assess your patient to figure out where the symptoms were, where they were coming from, where they associated with their treatment or were they menopausal symptoms? So where would you start in your patient assessment? I'm going to call on Bron, put her on the spot. Well, I'm madly opening those really helpful documents that have been shared in the chat. I don't know what other centres use, but for all patients who come into and in cancer service at my hospital, we use the distress thermometer. So that assesses a variety of different symptoms, emotional, physical and also menopausal symptoms as well. I think it is important to try and determine if it is related to the menopause or if it is more of a physical symptom related to treatment. I'd consider if there's been any imaging or any investigations that could help determine if there is a physiological reason for these symptoms and then also have a discussion with the patient as well to assess if there's any, what her menopausal symptom burden is like as well in regards to vasomotor symptoms, brain fog and other symptoms as well. Can I ask, Bron, do you use the general NCCN distress thermometer? Are you using the Gynie specific distress thermometer? That's a very good question. And considering we were one of the sites for the Gynie specific one, we are still using the overall distress thermometer. There have been some initial discussions to implement the Gynie one, but from an overall organisation perspective, it's easier for admin staff and our cancer care centre where people go for chemotherapy. They see all different tumour streams as well. So it's easier. And what happens, sorry, I should backtrack a little bit as well, is that when our patients come into clinic and they get checked in administratively, they will be given the distress thermometer by the admin staff to complete while they're in the waiting room. So then it's completed by the time they come into a consult, still paper based, which is another issue. So I think from that perspective, it's easier to use it. I would love to introduce the Gynie one, of course, and we were one of the trialling sites for it. So would love for that to be a future statement. You're not on your own there, Bron, we are still using paper and we're still using the general one as well. Again, it's administered by admin staff when patients do check in as well. So it's not something that we're certainly looking towards moving to an electronic version, hopefully this year and also to using the general, the Gynie one that's more specific with the specific needs of that population. And I think that that would be helpful. Thanks for that, Bron. Chrissy. Back off that a little bit, Anne, too. So now those were some really great recommendations and just trying to assess and get a bigger picture of where it might be coming from physiologically. Kasha or Kayla or Lorraine or Andrew, are there any specialists that you think would be ideal to maybe get this patient in to see? Here in Portland, we have a vast number of menopause specialists that have been very valuable, even as an adjunct primary care, let alone in oncology care. So that might be a good resource just to be able to talk about, as Bron mentioned, the myriad of symptoms that can come, but definitely joint muscle pain can be a big one. Sometimes a dose change in the HRT might be valuable to at least have as part of the process to rule out whether or not that may be the contributing cause versus her treatment. So that that's one thing that we have utilised here that's been helpful. At the National Maternity Hospital, we're very lucky to have Deirdre Lundy and I can't think of Claire's surname with my brain fog, but they're menopausal specialists. So I probably would send them on to Deirdre just to get her opinion, because she is very, very good and she's very practical. I really, you know, other than support for the very abrupt, you know, the menopause, in terms of immunotherapy, I'm actually a very active learner today. I work in radiation, so I am here trying to learn a little bit about immunotherapy. So I am just listening to all of you and learning. I was going to say we have in here in New South Wales, in Australia, have just started some what's called the menopause hub. So we have specialist services across the state that have gynaecologists here in Newcastle. One of our gynaecologists is part of our menopause hub here that is treating those women with severe and debilitating menopausal symptoms. So we would certainly refer a patient like this through to the menopause hub, which is a multidisciplinary service that where the patient can see not only a gynaecologist, a GP, allied health, psychology, social work, physiotherapy, dietician. So it's a real holistic approach to assessing and managing their menopausal symptoms as well. So we're very lucky to have a service like that that we can refer these patients to. Extremely lucky, if only, if only we could have that here in the U.S. Yeah, you know, it seems so new here in New South Wales, but it's exciting. Sorry, Chrissy. No, it's OK. It feels very disconjointed in the U.S. It's not as smooth where they're, here's your entire team. It's, oh, we'll refer you out, we'll refer you out, we'll refer you out. And you hope you get a different person every time. You hope you get an appointment within a certain window, whereas that's kind of, it seems a lot more organized. And I think here in the U.S., it requires a lot of proactive patient advocacy, and not all patients feel comfortable doing that, not all patients feel empowered to do that. And so it's nice to have a comprehensive program like that and and something that's being offered rather than patients feeling like they need to fight in order to be able to have that expertise. I think it's also related to a patient's health literacy and what they have the knowledge of and without being sort of, I guess, navigating to the right place within the system. They can sometimes get lost and feel like they do need to manage it on their own. So I think as nurses, we can provide that support and give them that information if the services aren't there. But we can certainly lead them in in the right direction for the support that they do need. So I guess then, go Chrissy. I was going to call on Kasia to ask her about what she believes to be the scale for how, oh my goodness, my words are not working for me right now. How poorly tolerating this patient is of the PEMBRO, if she's scoring on the adverse events scale there, what score does she think she has? I imagine that Kasia uses it with research, so that's, I have a feeling she's no, no rookie to that. That or anyone else, if anyone has any feelings, what they believe this patient would be scoring. Well, Chrissie, I think the important thing here is the fact that pain is limiting the patient's activities. So we reference the adverse events scale here because it's what we've referred to in our treatment module on the nursing curriculum programme. And it really demonstrates this is a 43 year old woman who is no longer able to carry out her activities of daily living. So this is bordering, you know, it's a grade two, at least more likely a grade three. And I don't I think, you know, when you get to the point where it's limiting daily activities, kind of attributing it to menopause, it sounds more severe than than a menopause, even though she's only 43. And it's more like an arthritic type picture of a little old lady almost. And I think her. It's remembering that this is an immunotherapy, that it does cause these systemic responses where there's more than one joint affected. It started in the shoulders and the shoulders remain the biggest problem, but it also spread to her hips and her feet. And that kind of picture, it's just beyond the limit of her activities and her ability to to do her daily tasks really went above and beyond the joint pain that you'd expect with menopause. I think that's great clarification, because my next comment was going to be, you know, it's reasonable to start there. But then the next step is exactly evaluating the immunotherapy. And, you know, it's a trial and error process, right, to get down to exactly what the causes and what's going to create the benefits, because what happens when it affects someone's activities of daily living so significantly is then you have depression, and then you have, you know, so many other symptoms that fall out from that or side effects that fall out from that. So dose reduction of the of the pembrolizumab, considering the spacing of the treatment, can it be something three weeks, six weeks for three weeks, you know, just being able to kind of play around and see, giving a period of time off, does it get better when you take a break? So I think that that would be a part of the trial and error, but certainly something if the menopause was focused on first and it wasn't improving. So I'm just going to go back and just share those slides. Sorry. Hopefully they're there for everyone to see. Yeah, they're great. I want to move on. So using the assessment tool that Ashley has posted in the chat there, we can see it's a grade two, probably more likely a grade three arthralgia picture that this patient is experiencing. This CTC adverse events have a whole section on musculoskeletal issues, and it gives you a really good reference for that kind of really objective assessment. So the patient was referred to rheumatology and they completed a number of specialist blood tests. Our CRP wasn't too raised, so there wasn't an infective or a widespread inflammatory systemic picture. They did baseline x-rays of the hands, feet, the shoulders, and there was no erosive changes. And their initial diagnosis was immunotherapy induced inflammatory arthritis. And so the patient was initially treated with a short course of oral steroids daily for three days. And she had this, she initially had a treatment break, a two month treatment break. And then when she resumed treatment, she had the short course of steroids around the pembrolizumab administration. And she was seen back then three months later in the rheumatology clinic and again had kept track of her symptoms. And the first week after the administration of pembrolizumab, the bilateral shoulder stiffness was at its worst, particularly at night. It did respond to NSAIDs. And usually within seven days, the patient was back to her usual activities. So the rheumatologists were happy to categorize it as a low grade immunotherapy related joint inflammation. They didn't recommend any disease modifying medications. I suppose I've included that to say, you know, if it's a high grade joint inflammation, there are again specialist medications that medical oncologists and rheumatologists can coordinate on whether the patient needs those or not. And interestingly enough, they really advocated for physiotherapy to build up the strength in the patient's shoulders and joints so that she'd be better able to avoid or work through the kind of stiffness that she was experiencing in those first seven days after the pembrolizumab. So any questions on any of that? It was it was a really interesting case because I suppose I felt, you know, once the rheumatologist got involved that, you know, it was very clear that there was a significant quality of life issue here for the patient on her treatment and that because I think there are certainly my experience will be that arthritis is really considered an old person's condition and it wasn't maybe seen or assessed in that systematic way from the outset and from when the symptoms first came on. I just want to follow up on some of what you said to Sarah. So this patient came to you and was expressing her discomfort, correct? Yeah, yeah. What about patients that don't? Should we or does anyone here actually assess further into how the treatment is going for them, whether it be immunotherapy, chemotherapy, any of those major hormonal changes where you're putting them into a surgical or chemically induced menopause? Are there questions that we should be asking that maybe we're forgetting are so important, you know, to make sure that the quality of life for our patients are not just they're going through treatment, they know it's not going to be fun, but how do we make it better? In our department, when we start chemotherapy or patients on long term immunotherapy or they are doing chemotherapy before starting, we do go through the, we use eviQ here and that is CTCA, the assessment tool. We go through them and if they specify, say, some symptoms, say thrashing in the mouth or something like that, then we use a specific tool and dig deeper. And if my patient mentions they're showing pain, then we go through the musculoskeletal assessment and dig deeper and ask more related questions before starting the treatment. So that's actually a regular feature when we give chemotherapy. So that actually helps us to assess how the patient is going in day to day life with their chemotherapy and help us to organize more support for him in his journey. And that's before each infusion or treatment? That's correct, yes. That's wonderful. I was going to ask, are there any other tools that people are using? Sort of one that I'd seen was the UCONS assessment for patients having immunotherapy. I know that there's a lot of units here in Australia that people have sort of developed their own little questionnaire or tool to use. What are other people using in their services to assess patients? Have you developed your own or are you using something? Obviously, the CTCAE is the commonly known one that sort of outlines the symptoms and the different categories or stages of symptoms. Have other people developed their own or are they using something else that's out there? And I agree with Lubell, Evacue here in Australia has some great information around managing patients on different regimes that can be really helpful. Bron, what do you use in Queensland, do you know? For chemotherapy and immunotherapy? Yeah. I actually don't know. And this is one of the challenges I experience, unfortunately, we are quite siloed, literally and figuratively, we're in separate buildings. So I don't know what assessment tools they use. I do know that they use the eviQ resources quite heavily when patients are first diagnosed and come in for a consultation for information about treatment side effects and what to expect. But I don't know if they've developed something specific or the organisation has developed something specific. Hi, this is Katja. I just want to add, we do use CTCAE, but I think it's just very important to work very closely with other team members and just to kind of cover patient comprehensively. And we do refer, we work closely with other multidisciplinarity members just to kind of cover everything. But we do use CTCAE in our practices. Yeah, here in Victoria, in Mercy Health, we use eviQ, but when I work in Peter Mac, that's one of the biggest cancer care hospital in Victoria. They have their own tools, which is incorporated in the electric system, so the electronic system. So they do not use eviQ, but they have their own tools, which is based on eviQ, but based on their research and stuff as well. Which we are not. And having something that is embedded within the system that you're using to document things, and it makes it sort of, I guess, easier to be able to assess when you've got it sort of in front of you, as opposed to having to, I guess, pull out the CTCAE or something. If it's embedded within the system that you're using to document, you know, your consultation with the patient, it does make it easier to have that there in front of you. Very true. Which is great. Yeah, yeah. It's, we have an electronic system, and I'm just thinking about our own, and we don't have anything that digs nearly deep enough to thoroughly assess these patients. So as nurses, we're relying on the practitioners to catch it, and we know that that's just not always feasible either. So, you know, it's making me think, what ways can we adjust our practice to make sure that there's not patients slipping through the cracks? I agree with you. You're absolutely right, Chrissy. That's how our workflow is here. So what I've done is I've incorporated follow-up calls that I do with patients. So I just set myself reminders to check in, particularly with patients that, you know, I do pretty comprehensive teaching prior to starting. And so that's really a great opportunity for me to develop a relationship with the patient in order to create a rapport where they feel comfortable calling. In fact, often my messages are patient calling just to talk with Andrea, you know, no further other information, just please call me. So then we end up having a long discussion. And it's interesting too, because our institution has just started to implement time tracking. And their idea behind that is they're gonna start charging for our services here in great America with wonderful medical care, which is a positive, you know, because it's recognized and it's a negative for those who can't afford it. So all that to be said is it's hard and gynomic to explain sometimes that our conversations with patients are not always specific to their treatment or side effects or symptom management. It might also be how they're just feeling constitutionally and, you know, how life is and things that are going on in their life. And being able to address all of those things is really important in my opinion in real good nursing care. And so those initial meetings that I have with patients give me an opportunity to kind of also recognize who are those patients that are gonna call, who are the patients that may not be likely to call so that I can keep an extra close eye on them. So, and then my providers too, you know, I've had this discussion. We have periodic team meetings within our provider group and myself as the nurse supports the practice of if there are patients that you feel in during your visit, you only have your five or 10 minutes with them. I totally understand that. But if you get a feeling that they would benefit from me going in the room and having a further discussion with them, please let me know. And that's often how I meet with people as well and capturing them in clinic is always nice because you're in person versus something over the phone or a virtual visit. So true and it's great that if your services can be, you know, have fees or billing attached to it so that you are, they are saying the benefit of what those conversations. And I think some of those conversations where you're just having a chat with the patient, you can actually get a lot from about what's going on with their life and their quality of life and how their symptoms are affecting them. So there certainly is, you know, a benefit of having those regular follow-up with patients, whether it be face-to-face or over the telephone. And you do gain so much information. And I also agree with you, Andrea, about it's how you set the patient up from the very beginning, the education that you provide to them prior to treatment around what to expect and when, you know, things change for them or they feel symptoms, what they should be reporting and that they can feel comfortable enough to report those symptoms if things are different for them, because everybody experiences these things differently. But if they have that rapport with you as the nurse to be able to, you know, tell you what's been going on for them and then you can really get a really understanding of what their symptom burden is on these types of treatment. Also a value, thank you for saying that. I appreciate that. The funny caveat is that sometimes you all of a sudden become the primary care provider's nurse at the same time. And you're like, all right, wait a minute here, you know, prolonged cough that isn't related to treatment. You just have had a cold and, you know, those kinds of things. So anyway, but I did also want to say a valuable resource for me, because as a nurse care coordinator with this group, I don't have a lot of contact with the other nurse navigators. We're very, you know, because we're kind of more of that intimate group, right? That subspecialty of oncology care, but having a good relationship and rapport with the infusion nurses, who are the ones that see the patient for every single one of the treatments. And so I will commonly get a Teams message from one of them that says, you know, I think so-and-so would benefit from you coming over, or it seems like a further education about this would be helpful, or this, you know, this was mentioned as a side effect or a symptom that they're dealing with, and they realized they didn't mention it to the provider, or did you know about this? I think that they, so having that kind of rapport and communication with that team is really helpful. And I feel like it's another way that we help to prevent things from falling through the cracks. Yeah, it was interesting, Andrea, now that you say it, because when the patient became menopausal initially on her induction chemotherapy, the idea of starting HRT while on treatment was not really entertained by some within the medical oncology department. It was something new for them. They would usually wait until the patient had finished treatment to start HRT. But in the meantime, like the patient is coping with all the side effects of chemotherapy and treatment-induced menopause. So there was a real education piece that we had to do around that to say, look, it is safe for the patient to start HRT while on treatment. So yeah, really interesting point. And that's a new transition that we've also been doing with our providers too. And it made me think a lot of the presentation back in the fall from the meeting when we really talked about that. And I felt like the group who was listening really, I mean, the talk even went later than it was supposed to. It leaked into the break because this was something that's really new and is continually being implemented at a lot of institutions. You know, an interesting thing to think about is listening to you all. I, you know, I'm a patient coordinator, patient navigator, but this makes me really realize how, I don't know, siloed, I guess, even after being in this field for a long time, that my practices, I have patients that we're treating with external beam and brachytherapy for cervix, and I'm so focused on the radiation, a lot of them are now getting Pembroke. I'm realizing I've got a big gap here in my knowledge of the way I think and assess them. I'm so focused on radiation where a lot of them are starting, you know, a lot more getting this than before, so this is a really good eye-opener for me. Bron's got her hand up. Yes, thank you. Something that we've been experiencing in Australia, and I don't know if it's a global issue as well, has been there's a shortage of menopause replacement therapy, specifically the patches, which has had a massive effect for our patients and of course women across Australia as well. So I was just curious to know, given everyone that's in the room, if that's been an experience for everyone and also how you've overcome that too. Yeah, we've a huge patch shortage at the minute and the alternative patch that have been sourced, there is a multitude of dermal issues with them. So patients getting a lot of rashes, a lot of stickiness, a lot of discomfort, and then these patches falling off, they don't have the same hold. So for some, we've a very Irish solution to an Irish problem. The northern part of Ireland is within the NHS, so we've been able to contact some chemists over there. They have a population of 60 million people, so they have much more buying power when it comes to HRT. So we've been able to secure supply through there, or we've had to change formulation. Patients haven't been able to get it, have to pay for more for stock that comes from the UK and are either switching to this spray, Linseto spray or the gel, which we don't have shortage of for the moment. And that's a really unfortunate case because they're either becoming very menopausal during the switchover or it's more of a burden to do a daily application than twice a week, particularly for young women who are maybe in survivorship and have a busy life and kind of want to just get on with things. So yeah, it's been difficult and it doesn't really look like there's an end in sight to it. Unfortunately, our pharmacy colleagues aren't very positive or optimistic about it. I haven't had a ton of exposure to whether or not our patients are having a hard time getting the prescription, so I can't provide any good insight from my area. I think that's what we are doing in Victoria here as well in Mercy Health. We are trying to get them to move, because of the shortage, we're trying to get them to move on to the gel version of it. And that don't have shortage at this stage. So that's what we are doing here for their replacement. Yeah, and we've been the same in Brisbane as well. We have been encouraging women to use, you know, gel or other formulations. But like Sarah has said, you know, the compliance and adherence is therefore an issue that regular re-application, remembering to do it when they've got busy lives and they've got a lot going on has certainly been a challenge and no end in sight either that I'm aware of. So thank you all for your thoughts. No, it seems to be ongoing, Bronwyn. And I think, yeah, we're using the gel as well. And it's, I think I talk to the patients about making it part of your routine. You know, you have a shower and after you've dried, you rub it on your arms and flap them around while it dries before you get dressed, that sort of thing. So making it part of their daily routine. And it does only take a minute. And I do understand people are busy, but if it can help with their symptom burden, then I guess, you know, people are more likely to want to sort of persist with that application. I was just going to ask a question, Sarah, around the referral to rheumatology and to physiotherapy about what access people have for patients to be able to see those people. Do they, is that something that happens within the hospital system or they're being referred privately for those services? And how available are those services to the patient? Yeah, so our cancer centres in Ireland are very much part of the acute hospital system. So, you know, there's rheumatologists on site at all of the cancer centres and we've a good bit of clinical trial activity as well. So we've had very good buy-in from rheumatology historically since the introduction of immunotherapies. And, you know, it is all available both publicly and privately, depending on which whether a patient is using their own private health insurance or not. And it's, yeah, the wait times aren't massive and they do prioritise, they recognise that, you know, it's a potential treatment ending toxicity for these patients. So they do make an effort to see them quickly and to get them sorted. And again, all of the x-rays and things like that are all available within the acute hospital. So we've a good working relationship with rheumatology. And I suppose as the menu of immunotherapy continues to expand, they've only become more involved in the care of these patients, really. So we've some very good working relationships with them. So we've a very good and we've some very good working relationships there. And, yeah, the patients are, I suppose there's weird and wonderful things that can happen with immunotherapy, but the rheumatologists never seem to get too fluttered about it. So there's very good pathways there for review. Great. How have other people found that referral process? As Sarah said, I think it's very much multi-specialty collaboration. And as different immunotherapies come on board and the different, you know, possible side effects, it's really being able to sort of collaborate with those other teams to ensure that we're doing the best for the women that we're looking after. Here in Victoria, where I work, we do have every week, twice a day clinic for physio. So we do have on-site physio in our department itself. So that referral is quite smooth going over there. But because the hospital where I work is primarily women's health, we don't have rheumatologists on site. But we are next to, again, a multidisciplinary hospital, Austin Hospital. So that got rheumatologists. So any referral from here, immunotherapy goes over there for urgent review. So they do consider and take us in quick, our patients very quick. But again, it's more of collaborating with two different hospitals to get a patient in. So yeah, physio part was, is quite smooth for us. But then rheumatologists, again, it's a bit of a hit and miss. So yeah, a bit of a follow-up is required when we send the referral to get them through. For us, if we send anybody outside of our own hospital system, it becomes challenging to keep track of whether or not they're actually getting the services that they need also. And you're, depending on the word of the patient, which can be really good, but not so good if they're not a great historian. So at least if there's notes that can show progress or, you know, they're going two to three times a week, it's a little bit easier to make sure that they're having their needs met and meeting goals. I work at the cancer center in Charlotte, and we're very lucky. We have a lot of specialists on site. Patients can see them pretty much on the same day they can see the oncologist. And like, it's a very collaborative effort. We can talk to them. We can have a group chat, group emails, and everybody's very involved. So like, I think our patients are very lucky in that, in that way. Okay, I just included some references at the end here, one of which is those management of menopausal symptoms following treatment for gyne cancer, a really useful document that was produced last summer by the British Gyne Cancer Society in collaboration with the British Menopause Society. That is something I would recommend, even if you don't feel like you have a huge amount of menopausal management experience, it's a really useful document. It clarifies the evidence by disease type, so it's quite thorough, it's about 40 pages, but it's definitely worth looking at. And then, as Kayla mentioned, pembrolizumab was presented in locally advanced cervix cancer at IGCS 24, so it is coming down the line, having already been licensed in Ireland anyway for metastatic or recurrent disease, and I've just put the reference there for the Keynote 826 trial. And I just want to say thank you to everyone for coming to our first ever Nursing Echo. This was a really phenomenal experience, and I feel so fortunate to be able to have you all join us and hope to be able to host more of these in the future. I think I speak for all of us over at IGCS, especially this nursing group. We've worked so hard and tirelessly to try and bring you curriculum and educational opportunities, so to have everyone be able to finally meet in a live, we're able to speak and have a conversation and a dialogue and exchange about how we practice versus you practice is just wonderful. So going forward, we are hoping to be able to host these bimonthly, looking to schedule another one for March. And we encourage you to ask questions, offer opinions, bring cases. If you have a case that you think is something that we should discuss here or that you really want to know how the other side handles it, please send it to us ahead of time, and we're more than happy to have you present that case for us and us to have a discussion about it. So thank you all again. So if you want to be involved and you do have a case, if you can just send an email through to Ashley and she's just put her email address in the link. And as Chrissy said, we are planning to have another meeting in another echo in March. We haven't decided on a date yet. And also if you think there's a better time of day or a better day of the week that would suit people to be able to join, please let us know that as well, because we want to get as many nurses online as we can to be able to have these really collaborative conversations and really see what's happening globally in gynae cancer from a nursing perspective. So thank you all once again for joining us. And if you do want to be more involved, please don't hesitate to reach out because we'd love to have your involvement with this group further for more exciting things to come this year for 2025. So thank you everyone for joining us. Have a lovely evening, morning, day, weekend, and we'll see you all online soon. Take care. Thank you so much. Bye. Thank you. Thank you, everyone. Thank you. Bye. Have a good day.

cervical cancer

immunotherapy

side effects

menopausal symptoms

interdisciplinary collaboration

patient education

CTCAE

gynecological cancer care