JuniorMedicoCancerCare

The World Cancer Day was started in 2000 by the Union for International Cancer Control to reduce the global cancer burden. Cancer is the second leading cause of death worldwide, with over 10 million deaths each year. 40% of cancer deaths can be prevented through modifiable risk factors like smoking, alcohol use, poor diet, and physical inactivity. Routine screening and early detection can prevent one-third of cancer deaths. 70% of cancer deaths occur in low to middle-income countries. Implementing prevention, detection, and treatment strategies can save millions of lives. The annual economic cost of cancer is estimated at $1.16 trillion. Cancer is curable if detected early. Cancer tumors can be benign, malignant, or pre-cancerous. Cancers are classified by the type of cell they start from, such as carcinoma, sarcoma, lymphoma, myeloma, leukemia, and brain/spinal cord cancers. Cancers can be caused by modifiable and non-modifiable risk factors Hello friends, welcome to this special podcast on cancer care. We are recording this on the World Cancer Day, 4th of February 2024. The World Cancer Day started in the year 2000 by the effort of the Union for International Care Control. And it's their initiative, which is the largest, oldest international cancer organization dedicated to taking the lead in convening capacity building and advocacy initiatives that unite the cancer community to reduce the global cancer burden. And they promote greater equity and integrate cancer control into the world health and developmental agenda. So we all are aware of this dreaded disease called cancer in some way or the other. And at Ritwimini Institute, whose knowledge partner is the Arogyam Institute of Integrated Medical Sciences, powered by Imzoni and Doctors, we felt like creating junior medicos of cancer care who are aware, who appreciates the various nuances of cancer care. And finally, who have the application background to use this knowledge for advocacy and a host of other issues. So as a part of this junior medicos of cancer care, this bulletin, this podcast is the base resource material, which you can rely upon to develop for the online assessment based on this very content out here. So some of the key startling factors which you want to discuss with you, that cancer is the second leading cause of death worldwide. Over 10 million people die from cancer every year. And more than 40% of cancer related death, they could be prevented as they are linked to modifiable risk factors. We will come to that, that what are the modifiable risk factors of cancer, which are smoking, alcohol use, poor diet and physical inactivity. So we can prevent at least 40% of the cancers. This is one part of it all. And almost at least one third, 33% of all deaths related to cancer, they can be prevented through routine screening and early detection and treatment. And 70% of the cancer deaths, they occur in low to middle income countries. The correlation is quite evident that early detection, screening and all is not possible in many places. And millions of lives, they could be saved every year by implementing resource appropriated strategies for prevention, early detection and treatment. So the total annual economic cost of cancer is estimated at around US dollars 1.16 trillion. This is massive. This is massive out here. So the part of creating these junior medicos of cancer care, you should be adept. You should be knowing these facts and appreciate the repercussions of these factors out here. So the actionable points which we can say that we have to make way for routine screening and early detection and treatment. So this is what goes on is that cancer is curable if detected early. So there is nothing to be so worried about it. And then modifiable risk factors which are preventive in nature, that preventing smoking, alcohol use, poor diet and physical inactivity, it can prevent at least 40% of the cancer cases out here. So what technically is cancer per se? So cancer is a disease which occurs when changes in a group of normal cells within the body. It leads to uncontrolled abnormal growth, forming a lump, which is called a tumor. And this is true of all cancers except leukemia. L-E-U-K-A-E-M-I-A, leukemia, which is cancer of the blood. If left untreated, tumors can grow and spread into the surrounding normal tissues or to the other parts of the body via the bloodstream and lymphatic systems. And they can affect the digestive, nervous and circulatory systems or release hormones that may affect the body function. So this is the simplistic definition of cancer per se. So cancer tumors, as we have just discussed, they can be divided into three groups. The benign, the malignant or the pre-cancerous tumors. Now what are benign tumors? They are not cancerous and they rarely threaten life. They tend to grow quite slowly. They do not spread to other parts of the body and are usually made up of cells which are quite similar to normal or healthy cells. They will only cause a problem if they grow very large, becoming uncomfortable or press on other organs. For example, a brain tumor inside the skin. So there are benign tumors. The second is the malignant tumor. They are faster growing than benign tumors and have the ability to spread and destroy neighboring tissues. Cells of malignant tumors, they can break off from the main or the primary tumor and spread to other parts of the body through a process which is technically called as metastasis. Metastasis is the process by which the malignant tumor spreads across and upon invading healthy tissues at new sites, they continue to divide and grow. And these secondary sites are known as metastasis and the condition is referred to as metastatic cancer. And the third, which are the pre-cancerous or the pre-malignant, it describes the condition which involves abnormal cells which may or is likely to develop into cancer. So benign tumors, the pre-cancerous or the pre-malignant ones which are on the verge of developing into a cancer and finally the malignant tumors, which were cancer actually started spreading in the body. So what early detection and treatment does is if it is done at the level of benign, if you have, we will come to that in what cases these screenings have to be done. So even if at the pre-cancerous stage the screening can be done, I think the treatment can be really started off and lives can be saved. Now what are the types of cancers? So cancers can be classified according to the type of the cell they start from. You all would have studied or would be studying the various cell structure of the human body. So there are five main types of cancers depending on the type of cells they actually start from. The first one is called the carcinoma. Now a cancer that arises from epithelial cells. Epithelial cells are the lining of cells that helps protect or enclose organs. Carcinomas may invade the surrounding tissues and organs and they metastasize to the lymph nodes and other areas of the body. The most common forms of cancer in this group are called the breast cancer, the prostate cancer, the lung cancer or the colon cancer. So as a part of your assessment, you would be asking like maybe breast cancer is a type of ABC, carcinoma or the various other technical names. So this knowledge, this awareness is so very important, which will make you a junior medico of cancer care. This foundation we are linked for you. Sarcoma is the second type of cancer. It's a type of malignant tumour of the bone or soft tissue, such as fat, muscles, blood vessels, nerves and other connective issues, tissues that support and surround organs. And the most common forms of sarcoma are leomyosarcoma, liposarcoma and osteosarcoma. Osteo is around the bones, liposarcoma and leomyosarcoma. So many of you would be aspiring doctors. So these are the complex terms which actually come forward in the domain of biology, medical sciences. So try to break them apart. Try to get hold and hang of these terms and terminologies, which are so very, I would say, openly discussed in the medical parlance and being a junior medico, I think you can pick up them very well. The third type of cancer is lymphoma and myeloma. Now, what are these lymphoma and myeloma? They are cancers that begin in the cells of the immune system. We all knew that we all have witnessed the COVID-19 pandemic where those who had high immunity, they could withstand the COVID-19 virus. So lymphoma and myeloma are the cancers that begin in the cells of the immune system. Lymphoma is a cancer of the lymphatic system, which runs all through the body and can therefore occur anywhere. And myeloma, yeah, it's also called multiple myeloma. It starts in the plasma cells, a type of white blood cell that produces antibodies to fight infection. So this cancer can affect the cell's ability to produce antibodies effectively. So many of you might even have not understood what is lymphatic system or what are white blood cells, but still being a junior medico, you can pick up these terms, understand and have faith. Oh, well, this is some term. And maybe when you get the opportunity to get to biology 101 in your senior classes or whatever, you can simply correlate with that. So the purpose of creating junior medicos of cancer care is to make them aware and appreciate of the various scientific terminologies, the phenomena around cancer, so that you become vigilant in your own families, communities, and at large to really challenge this dreaded disease of cancer. Leukemia. Leukemia is a cancer of the white blood cells and the bone marrow and the tissue that forms blood cells. And there are several subtypes of leukemia, which some of the common ones are lymphocytic leukemia and chronic lymphocytic leukemia. And the fifth type of cancer is the brain and spinal cord cancers. And these are known as central nervous system cancers. And some are benign while others can grow and spread. So these are the five types of cancers depending on the cells they actually start from. So a basic appreciation, a basic awareness and appreciation is important. Now what are the causes and the risk factors of cancer? So as we told earlier summarily that there are modifiable risk factors which can be prevented and there are non-modifiable risk factors. So the cancers can be caused by a number of different factors like various other illnesses. And most cancers are the result of exposure to a number of different causal factors. So as we told that some factors can be modified around one third of cancer cases. This is the global statistics. One third of the cancer cases that can be prevented by reducing behavioral and dietary risk. So here comes preventive medicine which we are treating here at Aarogya Institute of Medical Sciences. We really take a lot of pride and focus upon. So let's understand what are some of the non-modifiable risk factors and then we will come to what we can really control, what we can really prevent. So one is age which is a non-modifiable risk factor. Many types of cancer become more prevalent with age. The longer people live, the more exposure there is to carcinogens. Carcinogens are cancer-causing elements. And the more time there is for genetic changes or mutations to occur within their cells. So we can't do much about age. So that's one of the non-modifiable risk factors. So cancer-causing substances, they are called carcinogens. So they are substances which change how a cell behaves, increasing the chances of developing cancer. So genes are the coded messages inside a cell that tell it how to behave. That is which proteins to make and mutations or changes to the gene such as damages or loss can alter how that cell behaves making it more likely to be cancerous. So carcinogens are something which occur across ecosystems and things like that. Genetics is again one of the very strong non-modifiable risk factors. Some people are unfortunately born with a genetically inherited high risk for a specific cancer which is called a genetic predisposition. And this does not mean developing cancer is guaranteed. But a genetic predisposition, it makes the disease more likely. And for example, women that carry the BRCA1 and BRCA2 breast cancer genes have a high predisposition to developing this form of cancer than women with a normal breast cancer risk. But however, less than 5% of all breast cancers is known to be due to genes. So not very high. So although women with one of these genes are individually more likely to develop breast cancer, most cases are not caused by a high risk inherited gene. This is true of other common concerns where some people have a genetic predisposition. For example, colon, which is large bowel cancer. And finally, which we can't modify much is the immune system. Perhaps we have weakened immune systems genetically or by any other reason. They are more at risk of developing some types of cancer. This includes people who have had organ transplants and take drugs to suppress their immune system to stop organ rejections, plus people who have HIV or AIDS or other medical conditions which reduce their immunity to disease. Now, having said these non-modifiable risk factors, let's come to the hope, the ray of hope which is all out there, which is the modifiable risk. And as we have in the summary when we started off, we said that 40% of the cancers, cancer-related deaths can be preventable as they are linked to modifiable risk factors such as smoking, alcohol use, poor diet and physical inactivity. Let's discuss them in greater detail. So income and education levels, national policies, industrial tactics with vested commercial interest and genetics, they're all factors that can make it very difficult to act on a modifiable factor and they change the behavior of individuals out here. So alcohol, when it comes to that, the evidence is that all types of alcoholic drinks are a cause of a number of cancers and this evidence has got stronger than ever before. Alcohol can increase the risk of six types of cancers. Mind it, six types of cancers including bowel, which is colorectal, breast cancer, mouth cancer, pharynx and larynx, which is mouth and throat. The technical terms of mouth and throat in the medical jargon is pharynx and larynx and osteofagal liver and stomach. So wherever alcohol goes and makes an impact, so the entire food pipe and things like that. And the medical evidence suggests that in general, most alcohol drinks people consume, the higher the risk of many cancers and that even moderate alcohol intake increases the risk of cancer. So this is something which is highly preventable. It is in our hands that alcohol is a major cause of at least six types of cancers as we have called about it. The second one and very important is being overweight or obese. Excess weight has been linked to an increased risk of developing 12 different cancers, which includes bowel and pancreatic cancer. In general, greater weight gain, particularly as adults, is associated with greater cancer risk. In general, greater weight gain, particularly as adults, we are repeating it, is associated with greater cancer risk. So do physical activities. Don't let the weight come on. Don't get excessively obese. This can lead to cancer. So we have to have a longer life, healthy life. Let's, let's, let's. So how to do about it? The diet and nutrition. It's a modifiable risk factor. Experts suggest that diets and nutritional intake, particularly diets which are very high in red meats, processed meats, salted foods and low in fruits and vegetables, have an impact on cancer risk, particularly colorectal, nasopharynx and stomach. So let's have a healthy food, lots of vegetables and fruits out there, avoiding red meat, processed meats, salted foods, all the chips, all the processed stuff we are eating. Let's avoid that. Physical activity. Regular physical activity not only helps to reduce excess body fat and the cancer risk associated with this, but being physically active can help to reduce the risk of developing colon, breast and endometrial cancer. So let's be spotty. Let's do a lot of physical work out there as a junior medical aide. To promote that healthy living in your family and community and wherever you go as a paragon of Arugyata. Tobacco. Now, alcohol was the first menace and then tobacco. Tobacco smoke contains around 80 different types of cancer-causing substances. Cancer-causing substances are known as carcinogenic agents. When smoke is inhaled, the chemicals enter the lungs, pass into the bloodstream and are transported throughout the body. This is why smoking or chewing tobacco not only causes lung and mouth cancers, but is also related to many, many other cancers. The more a person smokes, the younger they start and the longer they keep smoking. All further increase the risk of cancer. Currently, tobacco use is responsible for, as statistics say, 22% of cancer deaths. One-fifth, more than one-fifth of cancer deaths are due to tobacco in any form. The other modifiable risk factor is ionizing radiation. Man-made sources of radiation. They can cause cancer and are a risk for a lot of industrial workers. These include radon, X-rays, gamma rays and other forms of high-energy radiation. So prolonged and unprotected exposure to ultraviolet radiations from the sun, sun lamps and tanning beds can also lead to melanoma and skin malignancies. So fair-skinned people, individuals with a lot of moles or who have a family history of melanoma or non-melanoma skin cancer are at highest risk. However, people of all skin tones can develop skin cancer, including individuals with darker skin. So this is quite preventable and if proper occupational care is taken, we understand that we don't have to risk ourselves to a lot of ionizing radiation. These cancers can be prevented. The next is workplace hazards. Some people risk being exposed to a cancer-causing substance because of the work that they do. For example, workers in the chemical dye industry, they have been found to have a higher incidence than normal of bladder cancer. Asbestos is a well-known workplace cause of cancer, particularly a cancer called mesothelioma, which most commonly affects the covering of the lungs. So these can be prevented for long. If we are aware, we can appreciate the dangers which are posed by them, and then we can apply, we can find out coping mechanisms, protective gear, so on and so forth out there. And infection. Infectious agents are responsible for around 2.2 million cancer deaths annually. We said total cancer deaths globally is 10 million. Now out of the 10 million deaths, 2.2 million cancer deaths are on account of infectious agents. Now this does not mean that these cancers can be caught like an infection. Rather, the virus can cause changes in the cells that make them more likely to become cancerous. So this is a virus causing cancers, infections coming out. So around 70% of the cervical cancers, the cancers in the feminine body, cervical cancers are caused by human papilloma virus infections, HPV virus, while liver cancer and non-Hodgkin lymphoma can be caused by hepatitis B and C virus. And lymphomas are linked to Epstein-Barr virus. Bacterial infections have not been thought of as cancer-causing agents in the past. But more recently, studies have shown that people who have helicobacter pylori infection of their stomach develop inflammation of the stomach lining, which increases the risk of stomach cancer. And friends, infection comes from various sources like there was a talk about diet and nutrition. If you are having unhygienic food, there is a lot of probability that these viruses, they enter through your body by the way of unhygienic foods and all. Now, you being junior doctors, like fair enough, all these are preventive aspects that we have to be free from obesity, we have to avoid alcohol, we have to avoid, we have to have a lot of physical activity, we have to avoid tobacco, we have to avoid iodizing, radiation, workplaces and so on and so forth. But what are the symptoms and signs that you might be on the verge, on the precipice of developing cancer? So this is something which as a medico, you would be learning about various, various disease conditions. But now since this certification is focused only around cancer, so what are some of the symptoms? Now people are saying, oh, the AI is coming, going to our help. But we have to, as a medico, you have to know, oh, this is the complex, this is the set of symptoms or signs which are taking us towards cancer. So the symptoms are varied because there are so many types of cancers. But key signs and symptoms which you would be, you should really have an eye towards, a reference towards. First and foremost is unusual lumps or swelling. Cancerous lumps are often painless and they may increase in size as the cancer progresses. So if there is any unusual lump or swelling, it is the first mark, a visual, without any testing of blood or any other biopsy or whatever. So unusual lumps or swelling is first warning sign it might be a cancer. And as they say that cancerous lumps are often painless. Coughing, breathlessness or difficulty in swallowing. Be aware of persistent coughing episodes, breathlessness or difficulty swallowing. This might be a sign or symptom of cancer. Changes in bowel habits, such as constipation or diarrhea and or blood found in the stools. So as medicos say that blood in a stool is a very, very strong marker or a sign of cancer for that matter. Unexpected bleeding. It includes bleeding from the vagina, anal passage or blood found in the stool. This is a red herring mark or in urine or when coughing. So if you are having unexpected blood bleeding from any of the cavities, any of the bodily, this is a very strong, very strong sign and symptom of a cancer. And that needs to be formally screened and tested upon. As we told that one third of the cancers can be prevented if we can do early screening and detection. Medical sciences have really flourished to that level. Unexplained weight loss, a large amount of unexplained and unintentional weight loss over a short period of time, which is to the tune of a couple of months, around 50, 60 days. If you have lost weight, unexplained, anyone of, so that is a big sign and symptom of cancer. Fatigue, which shows itself as extreme tiredness and a severe lack of energy. If fatigue is due to cancer, individuals normally also have other symptoms. So it is not a ruling out, but it is one of the parallel symptoms which we all see. Pain or ache includes unexplained or ongoing pain or pain that comes and goes, a pain which comes and goes. So that is also a cancer sign and symptom. New mole or changes to a mole. We all have moles in our body. If a new mole has come or you observe the change in size, shapes or color. And if it becomes crusty or bleedy or it starts oozing out, so it might be a cancerous sign and symbol. Complications with urinating. So it includes needing to urinate urgently, more frequently or being unable to go when you need to or experiencing pain while urinating. Appetite loss, feeling less hungry than usual for a prolonged period of time. So appetite loss is a strong cancer sign and comparative to having a diabetes factor where people have a lot of hunger. In cases of cancer, people lose appetite phenomenally. A sore or an ulcer that won't heal. So including in spot, sore wound or a mouth ulcer which is not healing for a long period of time and as somewhere a couple of months is a kind of a time frame which you should observe around it. Heartburn or indigestion. Persistent or painful heartburn or indigestion is something which is also a cancer sign or a symptom. And heavy night sweats. Be aware of very heavy drenching night sweats. So generally they say that not one marker but these are a mix of markers. So if some majority of these signs or symptoms are visible, so there is no harm in visiting a doctor. Somewhere or the other in our culture like visiting a doctor is considered to be scary. But no, we should keep on going and explaining our symptomatology to an expert medical. You are just a junior medical just to find out some 2 or 3 or 4 or whatever symptoms I am witnessing. So then quickly go into the refuge of a certified registered medical practitioner, your family doctor. He or she will guide, will take care of it and then refer you to a more specialized care if needed out here. So how can we prevent cancer and how can we detect cancer? So before we coming to it, cancer staging, let's know about it. The classification of cancer by anatomical extent of the disease that is a stage is essential for patient care. Research and cancer control. So staging system, it's called the TNM classification just for your knowledge because this has to be done by an expert. But yes, we should have a awareness of it. There are the 3 stages. The T describes the size of the main primary tumor. N describes whether the cancer has spread to the nearby lymph nodes. And M describes whether the cancer has metastasized. It has spread from the primary tumor to another part of the body. So the TNM cancer staging, we should have an awareness and appreciation of it all. Now how cancer can be prevented? So over third of all cancers, one third of the cancers, they can be prevented by reducing the exposure to risk factors such as tobacco, obesity, physical inactivity, infections, alcohol, environmental pollution, occupational carcinogens and radiation. So prevention of certain cancers may also be effective through vaccinations, say against hepatitis B, which is HBV and the human papilloma virus, which is HPV. We just heard our Honorable Finance Minister that the government of India will be going all out to inoculate, to vaccinate the girls in the age of 9 to 14 years against the HPV virus. HIV is the AIDS, but HPV is the human papilloma virus, which causes the cervical cancer. So HBV prevents liver cancer and HPV vaccine prevents the cervical cancer. So we should have a basic understanding of it all. So reducing exposures to other carcinogens such as environmental pollution, occupational carcinogens and radiation, it can help prevent further cancers. Now how to, this is the preventive part of it all. But then early detection is also one of the strategical arm of this entire cancer care, you being a junior medical of cancer care. So there are a number of cancers which can be identified early, which helps to improve the chances of successful treatment outcomes, often at lower costs and with fewer or less significant side effects for the patients. So there are cost effective tests that helps detect colorectal, breast, cervical and oral cancers early and further tests are being developed for other cancers. So check with your doctor for guidance on the national recommendations regarding vaccinations, testing and screening. And these can and do vary from country to country. So as we told you about the various signs and symptoms of cancer, perhaps you can map it all and see what is the sign or symptom matrix you are getting out of it. So detection, obviously, you have to go to a medical facility for examination, blood test, hormonal tests, so on and so forth. Now, once fine cancer as we have prevention is better than cure, you, but then cancers happen, 10 million people die of cancer every year and 2.2 million of them, they die because of infections. So if cancer has been detected and detected early, so what are the various management and treatment options? As a junior medical, try to understand that there is something called management like diabetes cannot be cured. It can only be managed. So cancer has to be managed and also treated. So management and treatment go hand in hand. So the treatment depends on the type of cancer. Now, this is all in the expert care. But then as a junior medical of cancer care, we really need to have an awareness and appreciation of this knowledge so that if there is some patient in our care, we can really extend that with an enlightened sense of mind. So the treatment depends on where your cancer is, how big it is, whether it has spread, which is called metastasized and your general health, what age group you are in. And the general types of treatments are surgery, chemotherapy, radiotherapy, hormone therapy, immunotherapy and gene therapy. So these are some of the treatments which are available. So surgery is if a cancer has not metastasized, which has not spread, surgery can remove the entire cancer, which may completely cure the disease. Often this is effective in removing the prostrate or a breast or a testicle. So this is one of the viable options. The second one is radiotherapy. Radiation treatment or radiotherapy uses high energy rays to reduce a tumor or destroy cancer cells as a standalone treatment and in some cases in combination with other cancer treatments. So this is a very emerging field that way. Chemotherapy, it uses chemicals to interfere with the way cells divide, like damaging of DNA so that cancer cells will destroy themselves. So these treatments target any rapidly dividing cells, not necessarily just the cancer cells, but normal cells usually can recover from any chemical induced damage, while cancer cells cannot. Chemotherapy is generally used to treat cancer that has spread or metastasized because the medicines travel throughout the entire body. It is a necessary treatment for some forms of leukemia and lymphoma. Now immunotherapy, it uses the body's own immune system to fight the cancer tumor. Immunotherapy may treat the whole body by giving an agent that can shrink tumors. Hormone therapy, several cancers have been linked to some types of hormones, including breast and prostate cancer. So hormone therapy works to change hormone production in the body so that cancer cells stop growing or are killed completely. And gene therapy, the goal of gene therapy is to replace damaged genes with ones that work to address a root cause of cancer, say a damage to a DNA. So other gene-based therapies focus on further damaging cancer cell DNA to the point where the cell destroys themselves. However, gene therapy is new and has not yet resulted in any successful treatment. But let's hope the kind of medical advances, by the time you really become formal medical, medical science would really improve upon to cure cancer in its entirety. Now two major other aspects like there is a concept of survivorship, which focuses on health and the physical, psychological, social and economic issues affecting people after the end of the primary treatment of cancer. It includes people who have no disease after finishing treatment, people who continue to receive treatment to reduce the risk of the cancer coming back. And people with well-controlled disease and few symptoms who receive treatment to manage cancer as a chronic disease. So we have in public life, we have seen a lot of celebrities who have braved cancer and come out as survivors. So this is the whole institution of cancer survivors. So survivorship care includes issues related to follow-up care, which is very important. The management of late side effects of treatment, the improvement of quality of life and psychological and emotional health. Survivorship care includes also future anti-cancer treatments wherever applicable. So family members, friends and caregivers should also be considered as a part of the survivorship excellence. So the whole gamut of being a junior medico of cancer care is that you also become an advocate in the survivorship club, in your family, in your community. You can be depended upon. And obviously, as a youngster yourself, you can promote the preventive aspect of cancers in a big way. And finally, the palliative care. It's painful, but then as medicos, we have to cover, as junior medicos, we have to cover the whole cycle. So palliative cover runs through a patient's journey from diagnosis to cure to, unfortunately, the end of life. And it's designed to relieve symptoms and improve a cancer patient's quality of life. It can be used to respond to troubling symptoms such as pain or sickness and also to reduce or control the side effects of cancer treatments. In advanced cancer, palliative treatment might help someone to live longer and to live comfortably, even if they cannot be cured. So this was the short bulletin we wanted to share with you on this World Cancer Day and as a part of, I would say, World Cancer Day and becoming a junior medico of cancer care. So I think these are some of the fundamentals which you have to be adept with. The awareness, the appreciation and obviously the application of the knowledge which you have got in terms of advocacy, in terms of linking up a prospective cancer patient. We talked to you about the various symptoms and signs and most importantly, preventing cancer, the healthy lifestyles, whatever we are having. So with this, and we would also like to tell you that search out your OTD platform and find out movies, the popular fiction movies or even the documentaries on cancer. Get up more material, the layman material out here and try to sensitize yourself out here. And as a part of the junior doctor cancer care certification, we might be asking you that which cancer film you have watched, what very perspective touched your heart. So there would be a bit of a subjective questions as well. So we hope that this bulletin comes very, very handy in your getting certified as a junior medico cancer care. Thank you very much.