Episode 93: Fundamentals - Part 2 of Pelvic Radiation Disease with Lisa Durrant

Late effects after pelvic radiotherapy part 2.

Join us as we complete our conversation with the wonderful Macmillan Late effects consultant radiographer Lisa Durrant.

Last week we discussed late bladder and bowel effects from radiotherapy.

In this weeks episode we discuss;

- hyperbaric oxygen therapy 

- pelvic floor exercises

- pain as a late effect of radiotherapy

- sexual function issues post radiotherapy

Lisa gives us some great practical tips on how to support patients after their radiotherapy along the way.

Enjoy!

For more info on pelvic radiation disease and late effects from pelvic radiation check out www.prda.org.uk 

Transcript

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Welcome back to the Simply Oncology podcast. Week two of our look into pelvic radiotherapy late effects and we welcome back the superb Lisa Durant from Taunton Hospital. Lisa, welcome back. 

Last episode we discussed bladder and bowel issues. In this episode we will discuss hyperbaric oxygen, sexual function and pain.

 And hyperbaric oxygen. So that's a really interesting concept, isn't it? So you go in the diving bell, a pressurised diving bell. And but, like radiotherapy is broken into sessions or fractions. Really. The hyperbaric oxygen can be 20 visits or something.

 Lisa Durrant   24:50
 S.
 None.
 Yeah, yeah.
 Yeah, yeah.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   25:07
 Something over four weeks or 40 visits over 8 weeks and you're in there. How long?
Lisa Durrant   25:08
 40 maybe 40. It's a big commitment. It's a big commitment. Couple of hours, I think. Yeah. So it.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   25:15
 Couple of hours. Yeah. OK, yeah. And that's and that's commissioned you can you can access that through the NHS, it's not a private service.
Lisa Durrant   25:22
 Each you know. No. We can access that through the NHS. Yeah, there are smaller centres around, but the pressures are different. And the great thing about the one down in Plymouth is that it's staffed by medical staff and the patients we've sent down there have had a really, really fantastic experience and been really well supported. So it's great however.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   25:25
 Brilliant.
 Yeah.
Lisa Durrant   25:41
 There was a trial, wasn't there? The hot two trial a few years ago that basically. Well, it didn't. It couldn't produce enough evidence to say that it should continue to be funded. But actually we found it has been useful for patients so.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   25:43
 None.
 When you, when you look at the evidence for hyperbaric oxygen, you see as many pros as cons. Like there's no real clear message.
Lisa Durrant   26:01
 Yeah.
 Yeah, but for some of these patients, there aren't any other options. So the other option is they have to go and have their bladder removed and that could be quite difficult in some of these patients because the tissues heal poorly and also things are very stuck together after they've had radiotherapy. So finding someone who will do that.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   26:07
 Yeah. Desperate. You just. Yeah. Bladder removed. Yeah.
 Mm-hmm.
 Yeah.
Lisa Durrant   26:22
 Type of surgery again, it's quite difficult any outcomes.
 Sometimes aren't as good as you'd hoped for. People still have pain and still have problems.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   26:28
 Yeah.
 Do you want to talk about pain? You've mentioned pain and that was a that was a. That was a new one to us. Do you want to talk to us about the pain side of things?
Lisa Durrant   26:35
 Yeah.
 So as part of the regional service, we've been very carefully collecting data, so all collecting the same data, which makes a big difference. So we just use standardised questionnaires and.
 We've been surprised at the at the amount of people that report pain, so perhaps over 80% of our patients. So that's all different sites report pain, which we were absolutely amazed about. The problem is on some of the forms, sometimes it's quite difficult to work out.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   26:56
 None.
 Mm-hmm.
Lisa Durrant   27:08
 What the pain is due to. I'm sure we're all very aware. Patients rarely just have radiotherapy, they have different modalities of treatment, don't they? So they might have had surgery before have and they might have some adhesions on the inside or they might.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   27:14
 Mm-hmm.
Lisa Durrant   27:24
 After the Radiotherapy so I know we were going to talk about bone having sufficiency fractures. They might just have chronic pelvic pain. So managing that again is quite difficult. We work quite closely with pelvic floor physios, actually, they've been a real godsend to some of these patients.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   27:40
 Yeah.
Lisa Durrant   27:42
 So exercising muscles correctly, some patients, if you've perhaps got a bit of bowel or urinary incontinence have got a really high tone pelvis where they're just trying to keep everything together all the time, which also can cause pain, so.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   27:55
 Mm-hmm.
 And does this lead us into talking about pelvic floor exercises?
Lisa Durrant   28:02
 Hopefully yes, pelvic floor exercises are really important.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   28:04
 What not?
 The most important thing that's hardest to do, I ask people to do it when they brush their teeth because we all do that twice a day. But I know it's more involved in that, but you can have involved and not done or simple and done. And I would prefer simple and done.
Lisa Durrant   28:16
 Yeah.
 Yeah, it's they need to be doing it properly though. Otherwise you can create more problems. They need to be doing it regularly, so making sure you're, you know, perhaps do it lying down, sitting down, standing up, waiting for the kettle to boil.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   28:29
 Oh, right. Tell us. Tell us.
Lisa Durrant   28:40
 Doing it regularly is really, really important and forever. Women are much more aware of pelvic floor exercises than men. Funnily enough, men that go for a prostatectomy are given information about perfect floor exercises. Sometimes that's just a leaflet and that's not great.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   28:48
 Yeah.
 Thank you.
Lisa Durrant   28:56
 But actually we should all be doing them.
 We you could.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   29:00
 We could be doing them right now, Mike and method please. So do you wanna give us, you know, do it right? What does that mean, not just squeezing it?
Lisa Durrant   29:07
 Do it right. So yeah, that's so we've got some really good information we give out. But for men, the little bit of information we give them is imagine you're getting into the sea and it's really cold nuts to guts. Is the phrase that the pelvic floors, which, you know, she is. So that's what you want.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   29:23
 Excellent. Yes. We like we like a catch phrase on this on this podcast, nuts to cats.
Lisa Durrant   29:25
 What are we doing so we get, yeah, nuts to guts. Yeah. Yeah.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   29:35
 And so we were talking about pain. We're talking about pelvic floor exercises, which help so many things and hopefully relax, that tense kind of tensing up in the pelvis, which you can cause pain.
 I think it's important to stress at this point that we are talking about patients that are then going to a specialist Lee effects service. I don't want people having radiotherapy to think that this is the norm and these are the patients that end up with problems.
 One problem that we are terrible at recording and kind of investigating and knowing about you mentioned the Joe's Trust survey on this sexual function after treatment. So for gyne cancer, we cause a lot of vaginal changes, vaginal narrowing.
 You know that lining changes that can cause bleeding, which is obviously distressing around intercourse, we cause all sorts of problems and it is vastly under reported do you guys have a flavour for that within your service?
Lisa Durrant   30:41
 Yeah, definitely. We see we see a lot of this. I think I think it's really difficult to know when to give people the information about this because obviously when they see you and they get a diagnosis and they have to make treatment choices and.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   30:41
 Yeah.
Lisa Durrant   30:56
 It's a whole different language and lots going on. And then I guess for a lot of people their sexual function is not very high on their list of priorities at that period in time. It's not until further down the line. I know we give people a female patients, all female pelvis patients should get vaginal dilators.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   31:07
 Yeah.
Lisa Durrant   31:16
 The ones handed out on the NHS are awful. They're awful, aren't they? So they are. Yes, you're right. But actually the timing as well is terrible, isn't it? So probably when they finish their radiotherapy, that sternal beam before they go for brachytherapy, someone will have a conversation with them.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   31:19
 Well, they're NHS though. There's come on.
Lisa Durrant   31:33
 And so here, take this set of vaginal dilators and you need to use those switch whatever and they it's terrible. Everything's really sore. They've got all these acute side effects. It's the last thing they want to hear, isn't it? So a lot of patients who see further down the line either haven't used them.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   31:44
 Hmm.
Lisa Durrant   31:51
 And they're never going to use them. Or they've perhaps had big surgery and they're a bit nervous about having the intercourse again, or they've got really bad vaginal stenosis. And managing that is really difficult. So what we need to be doing is trying to be a bit more prospective about this by giving people better information.
 So now within the services, we're trying to have better conversations with people. We're trying to make sure that people are either given vaginal moisturisers or vaginal oestrogens. And actually there was a great document out from the British BCG, British Gynae Cancer Society and the British Menopause Society. That's got a really.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   32:26
 So obviously, yeah.
Lisa Durrant   32:29
 Good traffic light system on who can have vaginal oestrogens and who can.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   32:32
 Lisa, you are right on message because we've just released an episode on episode 3 episodes with Rebecca Bowen about how useful this is in breast cancer. And we're doing some episodes in gynae cancer about these BGCS and Meno dot pause. Pause that. Yeah. Yeah. So perfect. Perfect on message.
Lisa Durrant   32:36
 Yes.
 Yeah.
 Right, yeah.
 Perfect. I'm glad to hear it.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   32:52
 Promotion there. Well done.
Lisa Durrant   32:54
 Thank you. I think I think having honest conversations with people as well, it takes a long time to have these conversations with people. They've got to really trust you to give you information. We spend a lot of time.
 Talking about different things people can use instead of vaginal dilators. Have you seen? Oh, nuts? Great thing. Oh, nuts are brilliant. They're like rings that go on the end of a penis so that penetration's not as deep, which is great. So if you've got vaginal stenosis, or perhaps if you've had.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   33:15
 Yes, yes, I have.
Lisa Durrant   33:27
 Had surgery and as you said, whatever these could be real game changers. The men with prostate cancer. It's also quite, quite difficult and takes a lot of time to have these conversations with people.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   33:40
 Mm-hmm.
Lisa Durrant   33:42
 Quite often we waiting. It's too. It's too far down the line, isn't it? So it might be after two years and I hear quite often patients. I never knew it was going to be like this. I never knew that I'd have erectile dysfunction.
 It's quite difficult with these patients to work out what's due to the radiotherapy and what's due to the hormone therapy. In a lot of cases, but actually if they're on hormone therapy and everything has shrunk, there's no point in that point in telling them that everything's going to go back to normal and it's going to be fine. So I think making sure that patients have better.
 Information at the start is really, really important. I think the other group of patients that's quite interesting is the colorectal cancer patients. So some of the patients that were treated for colorectal cancer years ago where they used to have bone treatments, remember that you get them lying down.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   34:32
 Yeah.
Lisa Durrant   34:33
 Before, say, before they went for surgery, actually their prostate got the got the whole whack of the dose as well. So a group of patients who aren't on hormone therapies so probably have got libido and still want to have an active sex life, suddenly have got all these challenges that they'd never realised we're going to be coming towards them.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   34:40
 Hmm.
Lisa Durrant   34:52
 So I guess we think about the traditional problems with sexual function, which is sort of the service cancer patients and the prostate cancer patients. But actually there's a whole bigger group of patients as well.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   35:05
 You touched on a very interesting going slightly off topic here, but you so you mentioned that we used to do things prone. We used to do a lot of things differently and technology advances in radiotherapy have mean have meant that we can shape the dose better. We're trying to reduce the dose to normal tissues maximum dose to tumour.
 But one of the sort of downsides to that is we also get much bigger, lower dose bath over more of the tissue. So there's a bit of a downside, but that's also potentially allowed us to escalate doses to the tumour. So do you think these advances in technology have led to less late effects or is it actually just an ongoing?
 Going issue because actually we've changed things, but the doses are still the limiting factor to normal tissues.
Lisa Durrant   35:52
 I mean the only way to not have radiotherapy late events is to not radiate people. That's the bottom line. Certainly even low doses have toxicities, especially over longer periods of time. So if we think of different groups of patients, so perhaps if you think of lymphoma patients.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   35:56
 Yeah, yeah, yeah.
 Mm-hmm.
Lisa Durrant   36:07
 Who had treatment? Low doses long. You know, many, many years ago, some of our patients from the 60s and 70s have got really hideous toxicities from having really, really low doses. We also know perhaps some of the head and neck treatments. So low dose bath to the back of the brain with some of the head and neck treatments is perhaps linked to fatigue.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   36:18
 Mm-hmm.
Lisa Durrant   36:27
 Long term fatigue. So I think in the pelvis, even though we're giving lower doses, we still see toxicities. Yeah. And I think there's so much more to toxicities than just dose people are really complicated, there must be other factors in here. You know if you.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   36:34
 We're not saying lower their amounts.
 Mm-hmm.
Lisa Durrant   36:47
 If you smoke, or if you if you're diabetic and you've already got an element of vascular disease, is that part of this as well? It's more, it's more than just the dose and the fractionation.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   36:56
 Hmm.
 And with that you know that comment, I'm still going to go back to it. We're now giving 5 treatments for prostate cancer hypofractionation and we're going to be doing it for so many more things.
 Mike mentioned the technology is allowing us to do that. So we used to give 7 1/2 weeks of radiotherapy for prostate cancer. Now we've condensed those 37 treatments down to five, but five bigger treatments, excellent cancer control. This looks to be the same and excellent side effects.
 Profile short term, in the short term that we have followed things up in trials, but the clue is in the name here. Late effects. Do you feel that there's a risk that we could see more late effects with this?
Lisa Durrant   37:37
 So you fell.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   37:50
 Hypo fractionation revolution.
Lisa Durrant   37:54
 Yes, I think so. I think it's very difficult though because the trial data you're right is still immature. We haven't got, it's not, it's not far enough out, is it? So if you think of perhaps the PACE trials for prostate not really far enough out the whole point of hypofractionation is designed around your tumour.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   37:56
 Yep, Yep. No, that's good. Yeah, yeah.
 Mm-hmm.
 Yeah.
Lisa Durrant   38:14
 And your organ that you're treating, isn't it? It doesn't necessarily mean that. That's right. For all the other tissues around it, does it? So a high dose prefecture might be all right for your prostate. It might not be all right for erectile wall, it might not be all right for the nerves.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   38:21
 Mm-hmm. Mm-hmm.
Lisa Durrant   38:32
 It might not be all right for blood vessels. You know, I think we've concentrated very much on what's right for the tumour, but haven't thought.
 As much about the tissues around it. So we'll have to wait and see, won't we?
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   38:47
 Play song.
 Yeah, I suppose part of that is again looking forward, you hope that this will this these late effects as they become more and sort of the, the scientific and the public consciousness that more research is driven towards understanding why they come about because you're right, you know there's why does why does 60 grow in 20 faction in one man cause no late side effect.
 At all. And then in what looks to be a carbon copy matched person, who might you know that, as you said, I agree it is not about the dose, there is something else that is driving it. We just don't understand it. And so hopefully this will come out in future research that will start to understand biologically what is driving these late effects and can we?
 Can we prevent them?
Lisa Durrant   39:29
 Yeah, absolutely. Because we can't. We really can't predict at the moment, can we, when they come into your clinic, you can't predict there is some evidence that patients who have very severe acute side effects, they're going to be the ones that crop up in your late effects clinic. But actually that evidence, there was a paper out in 2001 I think about that that's been known for a long time.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   39:35
 Nope.
 Yeah.
Lisa Durrant   39:49
 We just haven't done anything about it, to be quite honest, but.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   39:52
 And what research is happening? Is there some kind of National Audit, national database trial that's happening at the minute that excites you that you think I can't wait to see what this teases out?
Lisa Durrant   40:05
 I mean there is there is actually quite a lot going on which pleases me, but again it's little pockets, isn't it? So I think what we need to start doing is collecting data on who's got load effects and what they've got a bit more systematically. And we showed in the Southwest that you can collect good data.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   40:09
 Good.
Lisa Durrant   40:24
 And it's useful. So we just need to scale it up and think about that there, there have been little pockets where they have done that and again that's been quite useful, but it goes in terms of research I mean.
 Yeah.
 We need to think about different things, don't we? So we need to think about predicting who's got late effects, and they've tried to do some work, looking at genetic signatures to see who's more at risk. And we haven't really got very far. But is that prediction wider than just doses? Probably is. Yeah. We need to look into preventing late effects. And actually there's some.
 Really interesting work coming out.
 From Anne Kilty and Ananya Chowdry, probably said that wrong as well. Looking at yeah, looking at giving people inulin so high, high fibre, because I think that actually the microbiome is really useful in these in these patients.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   41:05
 Yeah. Yeah, yeah, yeah. Big fan of Ananya. We've had her on.
 Mm-hmm.
 You know, again, it always comes back to the microbiome.
Lisa Durrant   41:25
 But it's actually could play a really protective effect in reducing levels of inflammation. Perfect. So we kind of predicting and preventing, but also we're still at the point where we actually need.
 Evidence.
 On how to treat and manage patients because we're really limited the best bit of information we have at the moment is the best practise pathway for the pelvic radiation Disease Association, which is based on expert opinion. But it's actually brilliant in helping us guide how to manage these people. But if you read the document, I think you'll see from some of the.
 Because they give about numbers of patients that have got late effects, the disparity in figures shows how little research there is. So it would be great if we could predict and prevent late effects and we really need to move towards that. But we've still got a huge number of legacy patients, haven't we that have already had treatment that we need to be offering some sort of.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   42:18
 Yeah.
Lisa Durrant   42:22
 To management for so lots to do.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   42:24
 And there still will be patients even if we say to them you are at risk of late effects, but you have an aggressive cancer. Do you know like sometimes you just have to accept there is a high risk, we know that people with high blood pressure, people with diabetes, people with vascular problems, they are more at risk of.
Lisa Durrant   42:37
 Yeah.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   42:44
 Radiotherapy late effects, but if they have an aggressive cancer and you're treating it to potentially cure it, that is a trade off. You have to you know that we all have to meet.
Lisa Durrant   42:56
 It is and I guess I guess that's basis of personalised medicine, isn't it? But medicine at the moment is personalised to your tumour type. Maybe your age. Maybe your comorbidities. I don't think we spend a lot of time asking people what they want

but actually how many people ask the patient what they want? You know, I've seen patients who wish they hadn't had radiotherapy. I can think of one patient in particular who ended up with insufficiency fractures, which after five years she's still got insufficiency fractures.

 ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   44:14
 Mm-hmm.
Lisa Durrant   44:21
 But actually, she didn't choose chemotherapy because she already had problems with the hearing. So all the side effects we see are just due to radiotherapy. But actually the side effects she had meant that she could no longer care for members of her family. She couldn't get out her quality of life was very, very poor.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   44:38
 Hmm.
Lisa Durrant   44:40
 There was a massive difference between surviving and living, and I think at the moment cancer treatments are still very much about surviving, aren't they? If you look at the metrics in in trials, it's all about survivorship.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   44:44
 Yeah.
 Sir.
 So true. So truly so. But the difficulty again with this is the unpredictability you could have been a 95% chance of being absolutely fine and it's that 5% group where it is, it can be really miserable and it really can. And that's when I when I'm talking to patients, I do say you know you've got a very, very good.
Lisa Durrant   45:07
 Mm-hmm.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   45:11
 A chance of being cured, particularly in prostate cancer, and being absolutely fine. But if you are the unlucky few, then it's really hard and it's really tough, but it's so it's so hard to get your head around it because at the time you've got the diagnosis of cancer and you all you want to do.
Lisa Durrant   45:28
 Get rid of it, yeah.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   45:28
 Is get rid of that cancer. So now I hear it's really difficult conversations now we've covered a lot and there's been some great, great topics there. So we've talked about pain which is new for us to be thinking about, but our bladder and bowel issues, sexual function, we've mentioned the pelvic.
Lisa Durrant   45:32
 Yeah.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   45:47
 Like insufficiency fractures, which can happen in a small percentage of patients but can take a long time to heal and need pain relief, have we got Lisa 3 takeaway points are by late radiotherapy effects?
 And the service thereof for our listeners.
Lisa Durrant   46:07
 Yeah. So my first point is late effects can be a really huge burden for patients. So symptoms we perhaps view as quite trivial. So perhaps mild pain, grade 2 urinary retention.
 Are not trivial for the people living with them. So if we grade urinary retention as grade two, that means they might need a catheter. That is not insignificant for a patient. So I think it's really important that we really try and appreciate.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   46:24
 Mm-hmm.
Lisa Durrant   46:37
 What these mean for people further down the line? OK, lots of symptoms can be managed effectively with really simple interventions and support from a dedicated late effects team. So we can actually really help improve people's symptoms.
 Or even help their understanding as to why they've got these symptoms and that can go a long way to really, really helping people. And then my final point.
 Was.
 Radiotherapy patients really need to be told about late effects and I think we're much, much better at that, but the missing bit is that they need to have a point of contact as someone they can get back in touch with because otherwise patients just get dotted around to their GP or they see lots of different people. So they see some of their bowel some of.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   47:13
 Mm-hmm.
Lisa Durrant   47:26
 For their bladder, someone for their bone, and they it's almost like they you just treated for a different bit or a different organ. So actually providing proper, proper holistic care for patients is really important.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   47:40
 And I think the national consent forms have helped put on the agenda the late effects because they are very clear and in black and white that that they're there. Lisa, that's been amazing. But Mike, what time of year is it? It is Christmas. It's coming up to Christmas.
Lisa Durrant   47:46
 Yeah.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   47:58
 Elise is very excited about that and for Christmas, I think everybody should get a Christmas wish. If you had a Christmas wish for pelvic lit effect services after radiotherapy.
 What would your wish be? And it could be anything.
Lisa Durrant   48:16
 I think I would wish for every region therapy department should have a late vet service. There should be someone in every department who's got expertise, has got the time and the support to do these roles because he's.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   48:24
 Yeah.
Lisa Durrant   48:33
 Roles are quite complex. They take quite a lot of setting up, but yeah, my wish would be that everyone had a later vet service and we were all really thinking about.
 How we can move forward together so whether that's collecting the same data sharing pathways or actually just kind of really moving forward so that people are properly supported throughout the whole of their treatment and beyond?
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   49:00
 Lisa, that's a fantastic wish and thank you so much for your time. Really. Yeah. Yeah, yeah, yeah. Well, we're working across the North Pole as we speak. We've got a quite substantial budget. Thank you so much for your time. A fantastic episode. Such a hugely important topic expertly delivered.
Lisa Durrant   49:04
 Can you can you sort that?
 Yeah.
 Yeah.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   49:19
 Thank you so much. Thank you, Lisa.
Lisa Durrant   49:21
 Thank you. Happy Christmas.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   49:24
 Happy Christmas.
 Excellent. Thank you, Louise.