Understanding Cervical Cancer with Dr Faiz (Part 1)
1:41AM Jul 14, 2021
Hi, good afternoon everyone, and good afternoon to you Dr Faiz. Thank you for joining us on this wonderful day and we sincerely appreciate you taking the time to share with us the importance of understanding and being aware of cervical cancer. To be very honest. It is quite interesting to see two men on screen. Talking about cervix. But as a son and a husband. I hope from this session I could learn, you know a thing or two about how I can care for my loved ones. So, thank you for, for giving us the time so now for our viewers and followers out there. You have an interesting background Dr Faiz You graduated from the University of Manchester. You did your training at the East Lancashire Hospital, and move to one of Europe's largest treatment centres, the Christie NHS NHS Foundation Trust, but decided to return home in 2014, you were in Sarawak. You did a lot of talks about cancer, and you're now a resident doctor at MAKNA, the Majlis Kanser Nasional. So if you don't mind, you know, sharing with us a little bit about, you know why you're such a huge advocator of for cancer, so that the audience and we could get closer to what really motivates you, in doing so.
Well thanks for having me, Alan, I think cancer is such an interesting subject, because you have this, this is almost new ish keyword that's probably never been heard of like the last 50 years. And there's always new research coming in about cancer, so you know, in cancer we always say: Never say never. You'll never say oh we find new there's always something new that we learn about in cancer, all the time. And the most interesting fact to me about cancer is how easy it is, especially in terms of certain cancers and especially towards cervical cancer, it is to prevent cancer and to detect cancers early yet, you know this is something that we don't, we don't do, especially in Asia, especially in Malaysia, so that's why I'm very passionate about talking about these issues especially cervical cancer because it's so easy to, to prevent and detect early.
Okay, so then I guess then, thanks for for highlighting the topic right like so, then, to help us understand better. So what is cervical cancer?
Well, I suppose to to start with that topic, you have to understand what is the cervix. The cervix or in Malaya we call Pangkal Rahim is actually the opening of the womb. So if you have the woman's uterus or the womb. Below it is two to three centimetres at the end of the womb is the cervix, and then the cervix opens to the vagina. So essentially is a, is a part as a muscle that that differentiates your womb, from your vagina. So if you have a cancer of you. It's called endometrial cancer or uterine cancer. If you have a cancer, your vagina is called the vaginal cancer, but cervix such a small part of your body. Two to three centimetres long only. yet it causes a lot of cancers, it's the ninth most common cancer in Malaysia. It is the third most common cancer in Malaysian women. So, such a small part of your body the cervix. Yet, you know, is the third most common cancer in Malaysia, it affects about 4000 Malaysian women. In the last survey that we did, roughly about 800 new cases of cervical cancers diagnosed every year in Malaysia. So it's, it's such a small part of the female anatomy yet. It is such a very important cancer to talk about.
So, okay, this is, this is quite a heavy topic I think just the introduction alone. That information suddenly I feel overwhelmed. So, I'm enjoying my from my own personal experience right my, my, my wife and I we are expecting, and we went through, birthing class, we, we also went through this course, to understand the female anatomy a bit better so that we also understand what we're getting into in preparation for the birth so we were also learning about, you know, the female organ right and. And now you mentioned this when I was trying to picture that okay where do I place the visual and try to understand what we're talking about. So, let's say we take it slowly now just to help me to understand this much better because you mentioned a small part of the body, 4000 over women would have experienced this. So if you could just kind of break it down, part by part, what are maybe the different stages of cervical cancer? Or, yup.
When we talk about any cancers in general it's very important to know about the staging of the cancer. But even before knowing the staging of cervical cancer we have what we call precancerous lesions. These are things that we can detect very early. What this means is, is that there are cells in your cervix that actually show signs of changing into a cancer but they're not cancerous yet. So these cells can be detected up to 10 years early before they develop into full blown cancer, and that's why we do pap smears. So before we talk about the staging of cancer. There are staging of precancerous lesions, and this is what we detect through cancer screening. Now when we talk about cancers in general, we have what we call early stages which is stage one and stage two, and later stages which is stage three and stage four. Now the survival as usual is usually highest in the earlier stages, the stage one in particular, the chances of survival is very high. When we talk about cancers, in general, especially in Malaysia we always say oh people will always die of cancer, there's nothing that he can do. I have cancer, I will die like this is not true, especially in early stages in stage one and stage two and even in stage three, the chances of survival is very high in cervical cancer for example, if you are detected in stage one, your five year survival can be as high as 90% 95% of the way. But unfortunately if you're detected in stage four, your five year survival equality is only about 20%, and chances are you will die before six or seven or eight year. So, That is why it's very important to detect cancers in general very very early and not in to talk about cancers also, unfortunately, in Malaysia. 40% of all cervical cancers is detected at a later stage, a stage three and stage four. This is so different compared to when I was working in the UK, where only a handful of cases are detected in stage four and with certain stage four, because this isn't because we don't have the screening programme that they do in the UK in Malaysia. For example, in Malaysia. Most cases of cervical cancers are detected at the age of 70 to 70, or sorry, 50 to 70. It peaks at about 70 years old. But in the UK, most of my patients were detected at least 25 to 45, and these are through screening processes. So, the most important thing when we talk about staging is that he, the earlier the status or the lower the stage is stage one and stage two, the higher the chance for survival. And in order for you to detect cancers in early stage, you need to look for it, you need to screen for these cancers
Thank you doctor and you know I think a lot of us don't think too much about cancer screening, because we don't think of ourselves as trying to hit that lottery Right. And, and you mentioned this now there was an interesting stat you were saying that a lot of them were between the early during the early 20s, and 30.
So, in the UK is detected quite early. Within 20 to 40, years old.
So how do, how do we raise this is a conversation with the women right because one, one part of the question is also about. Because cervix relates to the reproductive is related reproductive system. And you mentioned that at the age of 20 to 40 they would have detected in the UK, a lot of them so how should a female think about a planning for screening, why is it important, you know, it has to do to be related to the fertility?
So when we talk about cervical cancer and fertility, there's always two branches of a whether the cancer itself affects the fertility, or whether the treatment, affects the fertility. So, because Cervical cancer is often present in women of childbearing age between 20 to 40. We always, this is such a hot topic issue. So we always think about this when we treat the patient. So, cervical cancer on its own, rarely causes fertility issues, unless in later stages when it destroys the ovaries and the female hormones. So, so then it causes fertility issues but in early stages, it rarely causes fertility issues now treatment for cervical cancer for example, might cause fertility issues, radiotherapy might destroy your ovaries which produce your female hormones. So it might cause early menopause, whereas, whereby you can't have any more babies chemotherapy for example, might suppress a lot of your reproductive functions, but as soon as you stop chemotherapy, sometimes your reproductive function will return. So it's not a big problem. And the most important thing in terms of cervical cancer treatment is the surgery. Any cancers, if we can cut it out, we will cut it out. So that is why it's very important to detect cancer very early especially cervical cancer, because if detected early stages, we can spare the uterus or the womb, so you can still have your babies, we can, after you've had the surgery, but if detected in a later stage, we might have to remove the whole womb, and you have nowhere else to grow your baby. So when it comes to fertility and cervical cancer. The cancer itself rarely affects fertility, but the treatment can affect your fertility. But, the earlier you diagnose the cancer, the better the chance of your fertility being spread.
On that topic I think that this is this very important point because of cancer we should try to screen as early as possible so that we can address them. And you mentioned the important thing which is to, it's not about the screening, it's about the treatment right then. Then the next question I have is structurally step by step to say I'm putting myself in women shoe. How should I reduce that risk? How can I how can I reduce my risk of cervical cancer? Right, what are some things I can do?
Yes, so this is, this is a tool for you to know how to reduce your risk. First of all you need to know what are the risks of cervical cancers. What are the risk factors of you getting so look at the number one cause of cervical cancer. And this is true for almost more than 90% of all cervical cancers is HPV infection so persistent HPV infection, human papilloma virus is present in more than 90% of all cervical cancers. So that is the number one thing, HPV there's about, 80 different types of HPV is, But only about four for HPV that accounted for about 90% of all of the cervical cancers. Right, so that is why we have HPV screening, we have HPV vaccines to stop you from getting cervical cancer. So the number one thing that you can do to stop you from getting cervical cancer is to know your HPV status is the number one risk factor is persistent, HPV infection. The number two risk factor for cervical cancer, surprisingly, is having sex with men. So lesbians have a lesser risk of getting of getting cervical cancer, because, unfortunately, men tend to be a bit more promiscuous. So, and HPV is sexually transmitted disease. So, the more sexual partners you have, the more you have sex with men, the more the men have sex with other women, the more your, your chances of getting HPV. So the number one risk factor of cervical cancer is HPV, and this is an HPV is present in about 80% of all sexually sexually active individuals, and they might not even know it. So that is very, very, very dangerous. So the number one risk factor is HPV, number two is sleeping with men. Number three is sleeping with men with multiple sexual partners. So that is the number one thing, the number one risk factors for HPV, sorry for cervical cancer.
I think this is awareness is good. Then, I guess, from a female standpoint, then we know what are the things to look out for, and assess. And if we were to think about these three factors that you mentioned. And I'm aware. And then now I decided actually, I feel a bit uncomfortable or maybe like, I'm a bit worried about, because maybe I encountered this three. Then how can I, what are the available screening tests that I should do or how should I go about it's okay I know I need to go test it now just to be sure what's available out there?
Okay so it's so easy to detect. It's so easy to detect. Cervical Cancer early, like I mentioned before, we can actually detect cervical cancers, up to 10 years in advance, we can prevent your cervical cancers from happening, up to 10 years in advance. It's, it's Is this one one easy swab every three years. So I think a lot of women know about the pap smear test. It's where you go to see your doctors and then your doctor will take a swab of your cervical area, it's just like a cotton bud and you will do a COVID test, but instead of doing in your nose, They'll just putting up your vagina and, you know, just have a little twiddle on your cervix. If you're not comfortable with a male doctor you can request for a female doctor if you're not comfortable with a doctor, you can request for a nurse to do it. And it's not that hard, it's only five minutes, every three years. So within this three years if we detect anything we can treat it, and usually if you are regular with your screening, and we do it every three years, we can detect cervical cancer, even before it becomes cancerous. So that is why screening is very important, because we can detect it, 10 years in advance, and we can stop it from actually becoming cancer, but unfortunately in Malaysia. It's not a programme that is, we don't do the screening as a population based screening. So when I was working in the UK, if you are of age. My computer will automatically call you up, send us a send us an SMS and send you an email saying that you are of age, please go to your doctor to get this time, three years later my computer will send you another reminder, but in Malaysia, we don't have that system yet, so it is really up to the individual patient to recognise that hey you know what, I've had sex with a guy before. I don't know what he was like, I need to know my standards, so I need to take care of my own health and I need to go see my doctor every three years to get this done because cervical cancer. Remember ladies, is the number three cancer in Malaysia, and it affects about 800 people a year. And there's no reason why anybody should get cervical cancer because we can detect it, so so early.
And when you mean, Dr Faiz when you mentioned that it's so easy to detect the results right, what kind of results do we expect like when we look at it how do we read the, the different levels or thresholds or severity?
So when when you, like I said it's like a COVID test, whereas the COVID test you just take your cotton bud and put it up your nose, but instead of that we take the cotton bud and put the brush and put it up your vagina and into your cervix, and then a week later, you get the results. The results are basically looking at the cells of the cervix, whether there's any changes to to a normal healthy sale. So if you have a normal healthy cell that is, we'll say it's okay to worry about it, come back the next three years, and we'll check you again. But if we see some changes to your cell that hang on a second, this doesn't look quite as healthy as a normal cell. We'll call you up again, and then we'll say, let's have a look and investigate deeper into this. So it's just whether your cells from your cervix looks normal, or looks healthy or not
Understand. And so the moment you detect even a slight change, you will already start monitoring.
Yeah, we know that the changes, grow very, very slowly, for it to become cervical cancer, it usually takes at least three to five years. So we will monitor it from what we call stage one, pre cancer is not even cancer yet So stage one, a little changes itself, and then it becomes stage two of any reduction stage three, and then also maybe we need to remove it before it becomes cancerous. So that's why we, It's always good to screen yourself for cervical cancer because we can detect even precancerous changes before it becomes cancerous and we can remove those precancerous changes.
Understand, so that is so it is it seems to be quite sensitive. And I guess the good thing is that it develops slowly, which means we have plenty of time to detect it early. So one of the audience, actually, one question I see here one of the, they asked, actually, the doctor told the doctors they encounter do advise them to screen, annually instead of three years, but now they understand from you. It takes a while to develop, doing a more frequently, you do as early as possible, we can already start monitoring. So then the question is, do we do you suggest that we do annually or three years is, is, is good, what's your what's your opinion about that?
Actually, three years is a generalisation of what you should do if you are normal, and you continue to be normal. However, the actual recommendation, you need to do it once a year for the first two years. If you are then found to be normal, then you can subsequently have your yourself tested every three years. However, in any of these investigations in any of these years your doctor found some irregularities or there are risk factors for example you have family members with cervical cancer or you have other members with multiple cancers, for example, then your doctor might think, hang on a second, we might want to increase your cervical cancer screening to the yearly. So if you're healthy. If you don't have any other risk factors, then yes, you can get yourself tested every three years. But if your doctor advised you that in the found some changes or they found something that they are concerned about I suggest to do it every year, then I would follow that doctor.
Understand now. I wanted to segue into the treatment but before that I wanted to understand like is age, a factor, or expanding on the question here is this because we factor in age. There are also audiences who, who asked and if you're older, if you are over 60. Does that mean you need to do still need to do, do you need to do more frequently, perhaps in a test for example.
Right. Well, age is always a factor in terms of any cancer, because cancer happens when your cells accumulate a lot of damage. So as you grow older, your cells do accumulate more and more and more damage. So that's why you when you talk about cancer and the cancer in general, you see a lot more patients in the older age range. So and this is true for cervical cancers as well. The more your body is exposed to HPV virus are the longer the HPV virus is in your body, the more damage it causes to your cervix and the higher your risk of cancer. So, as you grow older, yes you do get more and more cancers. So that's why in Malaysia for example you see the grass growing exponentially like that with the least number of cancer diagnosed at a younger age. The highest at about 70 to 75. The only reason that the highest incidence of cancer is detected between 20 to 40 in the UK is because we have a good screening programme. But if we let leave it to the to the natural cause, then the higher you are the older you are, the higher your risk of any cancer, cervical cancer, especially, and Kamala ask after 60 years old, you need to do pap smear. So, in all honesty, the guide, the guidelines from the UK has said that after 69 You can stop doing pap smears, this is only because after 69. We, our age range is no usually no more than 80 and cervical cancer is such a slow growing cancer, but it's less of a concern after that. But usually we say after 69. You can stop doing your pap smears. But only if your previous pap smears are normal, and your doctor thinks that you don't have any other risk factors.
Right now you also brought up to the fact that in Malaysia, right, because a lot of people may not be aware, and it's not like a national drive to call us up for doing such tests. Then the question is, for a shy Asian. Being in our culture. Before a female at a young age, are there telltale signs for you to kind of trigger us to, you know what it's time that I will do a test?
The thing with with with most cancers, is that we, we try not to wait until they're a symptom, because the symptom for cancer is very insidious, we rarely get to detect cancer early age, And usually when symptoms already appear. It's usually at a later stage, especially with cervical cancer. The symptom is usually spotting or pain during intercourse or after intercourse, or bleeding post intercourse, and a lot of women just think, you know what, this is normal, you know maybe I've had rough sex, Or maybe this is like remnants of period blood so a lot of women tend to just ignore this. So, I would rather not everybody rely on symptoms, in terms of detecting cervical cancer, and just follow the guidelines of these doing your pap smear every three years, and to detect early, and please, even prevent it, you know, try to reduce your risk factors, try to reduce the numbers of your sexual partners, try to get vaccinations early.
Now, on that word right vaccination then I wanted to kind of segue to then treatments, if you will the found there are some anomalies, what are the kind of the next steps right towards treatment?
Once we detect your cervical cancer. You can talk to your doctors about your treatment options. Please be don't be afraid of your doctors and we're very friendly, you know, I think, as doctors, we talk to you. And you can talk to us about everything in anything and talk to those about your concerns, if you are of childbearing age is still not finished completing your family. I thought you were saying that you know you want to continue to have kids, what are the options for that. But usually, for certain, for any cancer. The first step is always surgery. If we can remove the cancer, we will remove the cancer from your body, and then it's combination of chemo and radiotherapy radiotherapy is very easy. A lot of women think it's difficult, but it's actually just about five to 10 minutes a day, however long you need to do it, and then you don't even have to stay in the hospital, you can just go home and come back on a daily basis. Chemotherapy is something of an issue in Malaysia, because a lot of people think chemotherapy is so scary people die from chemotherapy, I will lose my hair, you know, but the thing is with chemotherapy is that we have babies as young as six months old having chemotherapy. Yes, I have a patient who's 95 years old, who has chemotherapy. So really if you are 40 or 50 or 30, you're fit enough test chemotherapy, don't worry about it so much. If you have any symptoms from chemotherapy, talk to your doctors, we can give you a rest, we can give you medication to help you with the symptoms, we can reduce your dose, if we have to. So, the best thing to do is - to talk to your doctors, clearly, hash out everything from A to Z. We will take all the time you need. We're not going to force you to any treatment. The decision is yours at the end of the day, so just talk to your doctors about your surgery, your chemo, your radiotherapy options, and you know just think it through. Don't rush into it, cervical cancer, especially is a very slow growing tumour. We're not going to say oh we need to start your treatment, tomorrow we'll usually say, take two weeks, three weeks, think about it, come back to us, don't worry about it.
Now that when you mentioned radiotherapy surgery. First thing in top of my head, it feels a bit intrusive. That's very, very serious already right. If you want to treat it even much early on, because you mentioned that the main factors to cervical cancer is caused by HPV, then, are HPV. HPV vaccines that are effective in preventing cervical cancer?
Okay. So HPV causes about 90 to 95% of all cervical cancers. So it's actually very so vaccinating yourself will protect you against 90 to 95% of all cervical cancers, automatically, there's something, a magic, magic pill essentially that can reduce your risk for this type of cancer by 95%, and it's not a difficult vaccine to take. It's been, it's been in the market for several years, I've taken it myself, yes men can take the vaccine as well. And for, for three vaccinates for three injections over the period of six months, it can protect you against 95%, of all cervical cancers. I think we mentioned, Kementerian Pendidikan Malaysia have have started vaccinating school girls 13 year old girls in school since 2010. So, if you are, if you've missed that if you're older, for example, and you have received your vaccine, and you're not yet in a committed relationship, so if you're still in the dating pool, you're, you're, you haven't. You haven't ended up with your Prince Charming. Or, if you, if you, you know, you need to get your vaccines. I always say please please please protect yourself. Yes you trust your your boyfriend. Yes you trust your husband. But at the end of the day it's your own body. Please, please take the initiative to protect yourself against HPV, if you're even if you're in a committed relationship. If you think that your husband will never ever ever ever ever cheat on you, and it's fine, don't take it. But, you know, if you have doubts just protect yourself.
Understand, so. So the key advice is, take the vaccine, whatever meat, meat, you can add early on, be responsive to yourself and take the test so that you're also aware. And then consult your doctor to get the best advice on what the next step is. Now, if the person, unfortunately, does develop severe cancer. How important can palliative care, help?
Yeah, I mean, again, when you talk about cancer when you talk about cancer in general. A lot of people think, Okay, I have stage four, I'm going to die from my cancer. What's the use of going to a doctor, you know, why should I go seek treatment. But even if your doctors can't do anything else to cure your cancer, there's a lot of things that doctors and nurses can do to help you with your cancer. Palliative care is not just about, it's not about curing the cancer, because we can't do that anymore when it's already stage four, but what we can do is we can delay the progression of the cancer, we can you know delay from growing bigger further, we can delay it from spreading to your lungs, your kidneys your brain, there's a lot more things that doctors and nurses can do in terms of palliative care, and the major thing that we do in palliative care is is controlling your symptoms and with late stage cancer for example, pain is the number one symptom that a lot of cancer patients complain about. A lot of people think okay it's just pain, you know, there's some panadol, there's some ibuprofen and that's it. But I will tell you right now, a cancer pain is the most excruciating pain you will ever experience in your life. If you are giving, if you're having a heart attack 10 milligrammes of morphine is enough. If you're giving birth some Pitocin is enough. But I have cancer patients who are on 60 milligrammes of morphine, plus ketamine, plus gabapentin, it's still not enough. So pain is something that we can help you with, and there's no other complications of cancer as well like kidney failure bleeding, urinary problems. So these are things that we deal with in palliative care, your nurses can help you with your doctors can help you with your homecare nurses can help you with. And beyond the physical can also provide you some emotional and some psychosocial support, because, by, by using palliative care. You can, you can actually give your carers at home some respite. It's not easy being a carer, so by the two hours homecare nurse come and help you at home. It gives you the care at home, some much needed help, you know by the one day that you're admitted in the hospital, perhaps, you know, your, your, your children or your husband was taking care of you at home, gets a much needed rest, so it's not easy having cancer and it's not easy, taking care of cancer patients, allow doctors nurses homecare nurses to help you with that to shoulder some of that burden as well.
I think in order for us to, to fight that journey towards recovery. It's important that we, we tried to muster as much mental strength, be in the best condition possible, to be able to go through the healing. And that's a, that's a very, very good point of the one right now, the biggest topic in the market right now in public, is that, you know, COVID is, is a big thing and everyone is waiting for that turned on for vaccines. However, like, even I myself sometimes when the, you know, if, let's say, I am going through certain treatment and I'm a cancer patient and going through treatment. Let's say cervical cancer for example, it is safe for me to go for my COVID vaccination jab?
Okay, so in terms of COVID vaccinations and cancer treatment for me cancers and cervical cancer inclusive. If you are currently on chemotherapy or radiotherapy, or any medication that might suppress your your immunity, you need to consult your individual doctors first because there are certain medication that you cannot take, or they can take while you're on while you're on while you take a vaccine. So, but if you are stopped chemotherapy if you stop, active treatment radiotherapy for example, you're a cancer survivor. That is absolutely fine for you to take your COVID vaccine is absolutely safe. I've taken two jabs myself, and all of my colleagues have taken the job. And so far, Touchwood. Nothing bad habit. So please please please if you have the ability, if you have the chance to get vaccinated, please do.
We have another question. So, from the audience, related to this, if they've already done surgery, they survived that first stage. What are the chances of recurrence? If I'm a cervical cancer survivor, we have recovered, what is the chance of everything, recurring?
With any types of cancer, the chances of recurrence is always there. And the chances of recurrence are highest is highest in the first year, and then it tapers off exponentially as you as you grow, as it as you get through the years. And so that's why it's very important for you to undergo regular doctor checkups, so that and that is also why in the first year, we follow you up every month, and then in the second year, every three months and then after that we follow you up every six months, because the chances of recurrence is always there, especially if it's diagnosed at a later stage, because the later, your, your cancer is diagnosed, the harder it is for the doctor to remove 100% of the cancer, so the chances of recurrence is there. It's higher is diagnosed at the later stage, and it's highest in the first year. So that's why you always have to be more more monitored more closely in the first year, less closely in a second year and so on and so forth.
So, this is so then there was one question here interestingly, from the audience also asking this because this is because we talked a little bit about prevention and now we talk about, how do we handle the recovery journey and what, what can we do to try to stay and monitor right. There was a question earlier we mentioned about HPV vaccines. Why is it important for men to also get the HPV vaccine? Because you kind of alluded, you kind of mentioned men a little bit as a culprit, one of the top three reasons for it, So, can you share your thoughts on that. Okay, so,
man. I'm talking to all the men in the audience. Let's face it, it's so easy for us to get sexual partners nowadays. Previously, you have to go out on a date, you take the bus to the to the post office in town and meet the go girl there, go out makan, but now all you have to do is just DM somebody through Instagram, or swipe left and swipe right on Tinder, to get your next sexual partner. Everybody now has a lot of sexual partners. So women, please be wary of men. If they see that oh you're my first, you're my only one they're lying, you're not their first and not the only one. And men, you need to take the vaccine because you need to protect your future wife, you need to protect your future pilots and men, and cervical. HPV doesn't just cause cervical cancer, it actually causes six different types of cancers, it causes oral cancer, esophageal cancer, it causes anal cancer if you do anal sex. So, HPV also causes anal warts and genital warts. So, with the cervical vaccine you you protect yourself against all these unsightly warts, but also you protect yourself against five different types of cancers. And for men also you can protect your future partners, against all these against cervical cancer. So, not just women need to take it, but men, if you have the chance, if you have the money if you have the ability, please take cervical cancer vaccine as well. It protects you against five different types of cancers is a protects your future partners against cervical cancer, And also it can protect you against genital warts as well. If you don't know what it is, please google up genital warts, and I trust me you will get the vaccine tomorrow.
Got it. Thank you. I will take a couple of questions, some more questions from the audience before I conclude with my last question. So now we're getting, I think, among the audience are building up some knowledge and awareness now, and they're being very curious. First question I want to take from from Miss Mei Ching her question was whether, you know, if results, as a result were to show any thickening or not sure what hyper means, in this case. She's worried about whether or not, is there a high chance of getting it right. But I guess consulting the doctor would be the right thing to do. What is your opinion for this question?
Well, pap smear results, usually they come up with grading, like for example a mammogram will tell you is breast, one, zero or 2, 3, 4, 5 with pap smear results, they usually will tell you a CIN: one, two or three. So, from there, your doctor will advise you whether you need to be monitored more closely, or whether you need to get treated for it to prevent it from becoming cancerous. So I'm not exactly sure what it means by thickening or hyper, but depending on if you look at the piece of paper again the you usually will tell you whether it's one, two or three, and your doctor will be able to advise you accordingly. Whether you either need to be monitored more closely, do a repeat test maybe in a year's time, do a coloscopy test or whether you need treatment.