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Special episode: COVID-19 update for health professionals

Special episode: COVID-19 update for health professionals

 

Let’s be Upfront about where we’re at with COVID-19 at the end of what’s been a difficult year for all Australians and our health system. In this special episode of Upfront, BCNA CEO Kirsten Pilatti is joined by Cancer Australia CEO Dorothy Keefe, who looks back at the impact of the pandemic on the cancer space, potential silver linings to COVID-19 and how we ensure we are equipped to deal with the ongoing effects of the pandemic in a COVID-normal world.

We recommend this episode of Upfront is suitable for health professional audiences.

This episode covers:

  • telehealth and areas for improvement in the system that harness the power of digital but remain consumer-focused
  • the impact of the pandemic on the people that work in the health system
  • hyperfractionation of radiotherapy
  • the role of the shared care model and optimal care pathway in 2021 and beyond
  • the potential impact in 2021 of the drop in breast cancer diagnoses this year due to the pandemic
  • a way forward for ensuring breast reconstruction is a priority in a COVID-normal world.

RESOURCES:

Upfront About Breast Cancer is a production of Breast Cancer Network Australia. Our theme music is by the late Tara Simmons, and this episode is proudly empowered by Red Energy.  

Want to get in touch? Visit our website at bcna.org.au, email us at contact@bcna.org.au, or call our Helpline on 1800 500 258

TRANSCRIPT:

Kirsten Pilatti [00:00:06] Welcome to this special episode of Upfront About Breast cancer, where we're taking a deep dive - and I hope, a deep breath - into the impact that the COVID-19 pandemic has had on treatment for breast cancer. And we will unpack the challenges that we as a sector need to work on for 2021. My name is Kirsten Pilatti, and joining me in this episode is Professor Dorothy Keefe, CEO of Cancer Australia. A medical oncologist, Dorothy has led and continues to lead a distinguished career focused on improving outcomes for cancer patients. A reminder that this episode of Upfront About Breast Cancer is an unscripted conversation with our guests. The topics discussed are not intended to replace medical advice, nor necessarily represent the full spectrum of experiences or clinical opinion. Welcome to Upfront About Breast Cancer, Dorothy.

Dorothy Keefe [00:01:01] Thank you, Kirsten. It's lovely to be here.

Kirsten Pilatti [00:01:04] Now I know we know each other well, so you are allowed to call me KP in in this discussion today as well. But it's so special to have you here and you, in fact, have a long history with BCNA as well as being on our board, before you took on this role as CEO of Cancer Australia.

Dorothy Keefe [00:01:23] Yes, I was very lucky and thoroughly enjoyed my time working with you guys at BCNA. And I think you do fabulous work and obviously work that can be translated and teach other advocacy groups around the country, in other cancer areas, how to best look after their patient community. So sorry I had to leave, but...

Kirsten Pilatti [00:01:47] You're still on our team! So it's been a it's been a tough year for everyone, hasn't it, from the patients through to the clinicians, through to the hospital systems and in fact, the government as well. Do you want to talk through us what you see as the situation right now, in Australia talking December 2020 and the impact that COVID-19 has had on us?

Dorothy Keefe [00:02:11] Certainly, KP. It was a completely unexpected year. Of course, we've always known that a pandemic was just one event away. And we've also always known, you know, we studied at medical school, what happened in pandemics and how they had waves and they came and went. But it was still a huge shock when it actually happened. And, of course, because there hasn't been such a huge pandemic for so many decades, it really tested all of our preparedness and systems and treatments for cancer have changed so much over the years that you couldn't possibly know exactly what to expect. So here we are in December 2020 in Australia, probably the safest place to be in the world with virtually no COVID at all. Community transmission has been suppressed and the only COVID cases are those coming in from overseas, repatriation of Australians who've been stranded overseas. So, of course, you know, there will be some cases, but we are the envy of the world. However, there have been major changes to cancer treatment during the year because of the pandemic. Right back at the beginning, I am sure you remember we had those discussions about whether or not it would be sensible to pause cancer screening. In the end, it was decided no, that it wouldn't be necessary. And I think that's right. But of course, some screening of some breast screening programs did close due to the issues with physical distancing. Note, I say that not social distancing; masks and hand washing, etc. And so there has been a drop off in diagnoses of breast cancer from that and from other reasons. And then, of course, there are the issues of what happens if people don't present with symptoms and if cancers don't get diagnosed, what the impacts of that are. And then there are the issues of how you care for people with cancer during a pandemic, how you make sure that all the service, the wraparound services happen. So it's been an enormous challenge, but of course, one that Australia has risen to and one that actually has led to some perversely wonderful outcomes.

Kirsten Pilatti [00:04:38] And there has been many silver linings. And I think when you reflect back, we need to remember those. But before we kind of go into that area, Cancer Australia's done a number of reports, one, looking at what changes of care did happen during COVID-19, but also helping us to prepare for the new COVID-normal. But I think, what's your personal opinion of what surprised you the most, do you think?

Dorothy Keefe [00:05:06] Well, that's a good question. I suspect what worries me the most was when we got those fabulous new MBS item numbers for telehealth and you know, at the beginning, as the Department is very fond of saying, you know, 10 years of of implementation was done in about 10 days. And we got telehealth and MBS item numbers in there, which means that people can be paid for doing telehealth, which needs to happen. The thing that surprised me about it was how little of it is actually done in video. So, you know, I think of now this is a new thing for me, thinking about communication in dimensions. One dimension is phone, two dimensions is video conferencing but three dimensions is the face-to-face genuine consultation. And obviously, telehealth is vitally important. And we're all delighted that the item numbers are continuing permanently. But we really need to get the numbers of video consultations up, because when Cancer Australia analysed the data, for the billing, it would seem that 98 per cent was phone only. And of course the reasons are complicated; people say not everyone can use video, and that's true. But what also happened was not every hospital had video cameras on their computer screens. So all sorts of things have to be fixed to make it work properly.

Kirsten Pilatti [00:06:33] Yeah, the system challenges then come into play. So you've kind of got the people element gets dealt with, but the systems and the processes then become the real challenge. And, you know, I was obviously very proud that BCNA could play a role in highlighting some of those telehealth challenges pretty early on, given that we did the COVID-19 survey of more than two thousand women and men who'd been diagnosed during that time. And, you know, clearly our data showed exactly the same as once we looked into the MBS data or Cancer Australia did, we were able to show what the personal impact is. And that data really demonstrated to the system the challenges that we still have ahead around telehealth. And I love that concept of three dimensional. And, you know, how do we make sure that we can embrace this telehealth in a way that's right for the patient, you know, making sure that we're not going back to the very reason why BCNA began where Lyn Swinburne was told she had breast cancer over the phone. So we've got to we've got to do better about that. So what do we do to make sure that we are doing better?

Dorothy Keefe [00:07:46] Well, I think actually you raise a really interesting point. What BCNA did was the same in some ways as what Cancer Australia did. We stopped at the beginning and said, where can we add value? What can we do that nobody else can do? Because everybody was obviously extremely busy, working really hard, trying desperately to make sure the system was ready and that people were safe. And so you and Cancer Australia separately looked at where we could operate and you can operate in the consumer questioning and communication area and we can operate in the national what is whole of system look like as opposed to individual jurisdiction or individual clinic. And of course, those things come together to say what we're trying to do is improve outcomes. So I think actually we've all been strengthened by the way we've had to work this year. And I think one of the really important things here is this issue that you've got to make sure you're asking the question of the right person. So when you ask clinical staff, what do they think about telehealth and what do they think about telehealth multidisciplinary clinics, everyone says, oh, yes, they're fabulous they're really...we don't have to travel! Yeah, but what are they actually like for the patient? So you've got to bring those two perspectives in together and you get these unexpected, sometimes unexpected, insights into what's going on. And some people actually really like having a video conference or even a telephone call, but not the first conversation and not the breaking bad news conversation. I think it comes back to all of the sort of m-health or e-health cancer care, where a lot of the supportive stuff can be done you know, let's use computers. Let's use AI, let's use any technique we can to speed up the bits that can be done by a computer or AI to leave room for the caring. The face to face, hand on shoulder caring that only a physical person can do.

Kirsten Pilatti [00:09:57] I couldn't agree more, and I think that really came through in the survey that we did and just the very simple things like making sure someone's with that person when you have those more difficult conversations. And I think there's still real challenges in the system around clinicians being allowed to have a person they're about to diagnose with breast cancer, bring in a support person. I mean, some of those fundamental almost we've taken them as a right were taken away from us during COVID-19. So we've got to make sure that we have a system that allows that supportive care to be the absolute focus.

Dorothy Keefe [00:10:42] You're absolutely right. And I think we also have to think carefully about what changes are evidence based and what changes are reactionary and how to gather the evidence to counteract the reactionary changes. And I think the one about having a support person there is really important. Yes, it was very important that we not spread the infection, but that doesn't mean you shouldn't have; if you weigh up the risks and benefits of having a loved one there while you're having the bad news broken, I suspect you could demonstrate that the benefit of having somebody that would be greater than the reduction in infection of not having the person there. And... Sorry, just particularly in a country like this where the infection level has been so low.

Kirsten Pilatti [00:11:36] That's right, and I remember so clearly, in fact, it was March 12 when we were sent a document of preparation of the worst case scenario, where we were deciding who could go to hospital and who could not. And it was so confronting. But actually having those conversations very early on, I think helped us to respond better to make sure we really were prioritising the people that needed us the most. But they were very confronting conversations that we were having in March. And thank goodness, you know, as a system and as a country, we haven't needed to make some of the decisions our European friends are making, which is literally sending people home without treatment.

Dorothy Keefe [00:12:19] Yes, I think the thing that we have to be eternally grateful for is that we didn't overwhelm our health system or come anywhere close to overwhelming our health system. That doesn't mean we didn't put a huge amount of stress on it. And I think that comes back to this you mentioned before about looking after our staff. You know, there is a huge amount of stress and anxiety just from having to work in this heightened attention area where you have to dress more carefully for work, make sure you put all your protective equipment on in the right order and that you don't touch any of the wrong things. That just adds stress to your daily job. So we do need to make sure once we're through the sort of acute phases that we actually look after everybody in the chronic phases to make sure people don't start falling over.

Kirsten Pilatti [00:13:15] Yeah, I know. And I think that that is something we all need to focus on in this summer period, is about the people who are in the health care system getting looked after themselves so that if there is more to come, then we can respond again, because there's no way we can continue to work at the pace that everyone has been since March. That's absolutely true. We've touched on a bit of the silver linings, anyone who follows me at all understands how important radiotherapy is to me on many fronts. But hyperfractionation is one of those silver linings that we were able to talk about very early on, where we saw once again something that was taking the system a very long time to respond to the latest in evidence for those particular women and men who'd been diagnosed, that they could have less radiation actually happened quickly. How do we hold on to those silver linings when we come out the other end? How do we make sure that continues? It's a very big challenge for us, I think.

Dorothy Keefe [00:14:24] Yes, I think I think it is a challenge for us. You know, they say in the sort of change management literature, they talk about sort of unlocking you from one position, moving you to a new normal and locking you down in that new normal. And so we have to make sure that we've locked radiation oncology down in the new normal, where the evidence shows that it's safe to do so and beneficial to do so. We should use hyperfractionation. And that's increasingly so for many cancers. I think one of the problems we have is and it's not it's not sort of isolated to radiation oncology, but we do have some perverse financial incentives in this country where - and it's not it's not the practitioners fault that this has happened, this is just the way the system has grown up - that that radiation oncology is paid per fraction of treatment given. But all the sort of intellectual grunt of the course of treatment comes at the beginning and isn't paid separately. So that it may be that we need to look at how we fund radiotherapy. And maybe, you know, I don't hold the policy levers here and I'm not in charge of this in any way, shape or form. And I'm not criticising anybody who is working in this area. But how about if we had a payment for planning; so front loaded the payments so that it wouldn't need to, you know, to recover the costs of treating somebody, you wouldn't need to give lots of fractions so that the bulk so it was paid for the work that was required to actually deliver the treatment. And so I think there are those sorts of things that we need to think about. And ultimately we should give the best treatment that has the least impact on the patient's life, which means, you know, once per dosing, once per cycle dosing of drugs and as few radiation fractions as you possibly can.

Kirsten Pilatti [00:16:23] And I think that's probably true of quite a number of areas, and we should always use a crisis for improving outcomes there's no question about that. But it also seems to me that this is the time for us to really think through the shared care model with GPs and fund that appropriately, too, so that we can really implement something that all of us understand and know that a GP is very important in the holistic life of someone who's been diagnosed with breast cancer. So, you know, how do we make some of those changes to the shared care model as well, where it's going to actually financially reward better supportive care for our patients at a more local level?

Dorothy Keefe [00:17:11] I think that is exactly right. It's another one of those areas where the evidence has been accumulating that a patient, or a person who's had breast cancer, doesn't need to stay under the care of a specialist exclusively for the rest of their lives, and we know from research that that women prefer to have some sort of a mixture of care. And we know that we should be using one of my favourite terms is that people should be operating at the top of their licence. So to a certain extent, it's not just GPs and primary health care physicians, it's nurse practitioners as well. If there is somebody who has the skill and competency to care for a patient who's had breast cancer and to know what the triggers are for a re-referral of that patient or rapid access re-referral to the specialists, then we should be encouraging that. Now, of course, the problem with COVID-19 is that actually the GPs were quite busy and so while we didn't going to the hospital, nor did we want the GPs overwhelmed suddenly with an increase in workload that they hadn't actually been prepared for or properly educated around. And so you have to take that balance somehow between the delight of people suddenly saying we don't want anyone coming to the hospital and everybody have shared care, to the poor, GPs being overwhelmed by that influx of patients. So there has to be a staged and appropriate way forward. But it has given us a boost in our efforts to try and get that to happen.

Kirsten Pilatti [00:18:43] So what is the next step to get us, not just from the enthusiasm and the boost, but into the actual implementation of what I think will probably be a new look, optimal care? You know, once we already know what best treatment looks like, but maybe it is looking at it in a slightly different way to when we have before COVID-19. But what do we do to actually bring this to life?

Dorothy Keefe [00:19:11] Well, I think there's a there are a couple of things that we can do. One of them is invest more in implementation and look at either I mean, I'm always a bit reluctant about pilots because they can tend to put things off, but staged implementation, demonstration projects using technology better. I mean, I think the explosion in IT solutions is actually our friend in this case, so that we can, you know, let's make shared care digital rather than just paper based.

Kirsten Pilatti [00:19:48] Absolutely. And you know, and also these, I think, preconceived ideas about the demographics of people who can use technology has also been really challenged. And I think when we launched the My Journey online tool, which was of course supported by Cancer Australia, that everyone challenged us, that the older demographic were never going to get online. But in fact, I think our oldest member on the online tool is 92. And, you know, our online tool demonstrates that people of every age are happy and in fact prefer to get online to receive their information because they know it's more up to date. They can watch videos, they can read if they want. You know, it interacts with them very differently. And I think what COVID-19 has done, along with our work around the My Journey online tool, is to demonstrate that actually don't have preconceived ideas with who and what uses technology to communicate or make, you know, to build their information support.

Ad [00:20:55] BCNA's My Journey online tool is a new resource that gives instant access to trusted and up to date information which is relevant to your breast cancer journey. For more information, visit my journey dot org dot au.

Kirsten Pilatti [00:21:09]  I did want to just touch on briefly how impressive the Aboriginal and Torres Strait Islander communities responded to COVID. Have you had time to reflect on what we might be able to learn from their absolute protection of community, not just in remote areas, but also in metropolitan and and, you know, semi regional areas, how well they have done to protect themselves against it and what we might be able to take from that into the cancer space?

Dorothy Keefe [00:21:42] Yes, that's a really impressive and interesting issue, isn't it? So for four decades, the Aboriginal Torres Strait Islander communities have been saying that they should be in charge of their own health care. And in 2020, they have demonstrated why it does actually make a difference. And so I think it it's a wake up call to all of us that maybe we weren't listening as much as we should listen and that we shouldn't do anything to a community, we should only ever do with a community. I think the idea of co-design and I know that sometimes we all think, oh, gosh, it takes longer when you when you do that. But if the outcome's better, then maybe it needs to take longer and we need to listen to that multitude of voices and to listen to how they looked after their own health care so well during the pandemic. So, yeah, I'm actually slightly in awe of what happened there and would like to make sure that I learn as much as possible from it so that I can use it to benefit the people with cancer to make sure whatever we do is properly in partnership.

Kirsten Pilatti [00:23:08] Now, one of the things I'm very grateful for is that our Aboriginal and Torres Strait Islander or in fact First Peoples, because that's what they want to be referred to here within Breast Cancer Network Australia, are all leaders in their own community and have been so busy looking after their communities around COVID that now they're coming back to us with an incredible learnings about how we can implement that change. And I'm really excited about the work we're going to be able to do with them in in 2021. I think, we talk about optimal care pathways and probably it's best known in breast cancer, more so than any of the other cancer groups, because our health professionals have been involved for so long in that development of the optimal care pathway and encouraging and involving consumers very early on. But I mean, if we if we think about what it's going to look like, what do you think will be the biggest changes, if we reflect back and say, you know, and in 10 years, looking forward, what do you think will be the biggest changes and lessons we've learnt about what is optimal care now?

Dorothy Keefe [00:24:20] Well, I think the optimal care pathways are absolutely vital as the basis from which everything else progresses. So, you know, I think you're right the breast cancer one's best known. But I think our Aboriginal and Torres Strait Islander optimal care pathway is really groundbreaking because it's not one tumour specific. It's a group of people specific, which I think is very important in this situation. And now with every other piece of work the Cancer Australia is doing, we're basing the work around the optimal care pathway. So, for example, at the moment we're making a road map for what we need to do in pancreatic cancer because pancreatic cancer outcomes are so poor. And we're saying, well, let's start with the optimal care pathway. If we just did all of the things that we know we need to do on this pathway, joined up all the care and linked it in with the Aboriginal or Torres Strait Islander optimal care pathway, we would definitely improve outcomes just by doing that, because we know it's not happening across the country and there are gaps between bits of care and blocks in the road, etc.. So I think they're a fabulous tool for holding systems to account. If a consumer and a clinician can say to each other and to the health system, this is what we should be able to provide or receive and we can't in this area because of whatever reason, then that holds people to account. And it's slowly, slowly beginning to have an impact, these things are very hard to implement like anything, but I think that the fact they're there gives us this strength, if we all agree with each other, we're very hard to overrule. So if everyone is saying, but I need to be able to provide this level of care because this is what the patients need, then 10 years’ time, I would hope that every patient is being treated on a cap on an optimal care pathway and that all of the things that we've learnt from COVID-19 are actually in place in terms of hyperfractionated radiotherapy, in terms of optimising tele medicine, because telemedicine, after all, just coming back to that was brought in because our rural and remote patients couldn't always see their doctor face to face. So we need to not lose sight of the really important bit. We just need to make it better. So  I think there will be benefits from COVID in the cancer arena once we get over this unfortunate drop in diagnoses that we're going to that we have seen. And that is going to have implications in the next year or so.

Kirsten Pilatti [00:27:08] Yeah, so let's talk about that. You know, one of one of the things I have loved is that cancer registries have been able to put out their data much faster than normally, which has allowed us to be able to see across the country the drop in diagnosis. Victoria clearly had the largest with the longest stint in a lockdown. And what do you see is the impact that that drop in diagnosis, I mean, I think you and I both were doing the rounds in the media saying that COVID had not cured cancer. So what is the impacts that we now need to plan for in that drop of the diagnosis of breast cancer?

Dorothy Keefe [00:27:55] So actually, of course, it's not just breast cancer. We've now seen the drop in the top one in five important cancers. So we've seen it in breast cancer, lung cancer, colorectal cancer, prostate cancer and colorectal cancer. They've all had a drop, but some worse than others. And some have recovered better than others. And of course, Victoria has had a slow recovery than the other states due to the second wave. So what is going to happen is that those cancers that were not diagnosed this year and I think we're probably looking at maybe seven or eight thousand cancers across the country, I'm just extrapolating that. Don't hold me to that figure!  I'm not saying that we know that there have been some. I'm just saying that we are down and we and there was a paper that I'm sure you saw from the British Medical Journal. It showed that every four week delay in breast cancer diagnosis equals something like 10 extra deaths per thousand or something like that. Yes. So I may have got that slightly wrong. But the principle is the longer the delay, the worse the outcome. And of course, in Australia, we don't usually have those delays. Those delays are evident in countries that don't have such good health systems as ours. And I would reiterate that Australia has probably the best health care system in the world, as we've just demonstrated through the pandemic, and we have the best cancer outcomes in the world. So we're talking from a position of great positivity. But there will be some cancers that will have been missed this year and they will present next year or the year after. And when they present next year or the year after, they will need more intense treatment than they would have done had they been picked up this year. The outcomes, survival rates may show a little bit of a dip. We will be working as hard as we can to ensure that the outcomes are optimised. But that does mean pressure on the workforce. It means pressure on the physicians who make the diagnoses. It is pressure on the surgeons, radiotherapists and oncologists who treat the cancers. And this is a point where we really need to, we're not going to suddenly be able to bolster their numbers because it takes a long time to train these people. But what we can do is put in supports underneath them to enable them to act at the top of their licence by having the nurse practitioners, the nurses, everybody, the admin people all working to the top of their licences to support the treatment of these people. Otherwise, we're going to have trouble.

Kirsten Pilatti [00:30:48] And certainly we are already seeing I mean, our survey indicated the anxiety levels from patients increased during COVID and now already through the Helpline, we know that the guilt that is associated with seeing a lump, feeling a lump, seeing a change, feeling a change and doing nothing during the pandemic and then being diagnosed later is going to add enormous burden to the woman or the man who's been diagnosed. So I think that it really does go to that discussion before around optimal care and making sure it's not just about a treatment transaction, but also about the supportive care elements. Because if we're already dealing with increased anxiety in the community, whether they had cancer or not, added to that where their life is turned upside down. Added to that, the burden of guilt, particularly for those women or men who may have progressed to have metastatic disease. You know what are some of the things we need to be doing now to prepare for that, do you think?

Dorothy Keefe [00:31:56] Well, I think the first thing is that there should be no guilt in having cancer. There should be no victim blaming, and there should be no stigmatisation of people. The reasons that people didn't, you know, present are not of their own making. And I think sometimes we need to say that to people, you know, do not blame yourself for this. This is out of your control. The health system was under crisis. And, you know, you were getting messages that that were not necessarily saying, come on down. It was quite hard to get in to see somebody face to face during the sort of the waves of COVID. So I think, you know, we need to make sure that the mental health, as well as the physical health of all of our patients is looked after, which again means we have to look after staff in order to look after the patients properly. So there is that balance. I think it's going to take the health system quite a long time to rebalance after COVID. And even though we're not in as bad a state as so many other countries in the world, that doesn't mean nothing happened here. You know, we still have to recognise that there was a big crisis here, too.

Kirsten Pilatti [00:33:22] Yeah. I mean, you know, another very important advocacy piece for BCNA has always been reconstruction. The greatest fear we have as an organisation who represents those people who've been diagnosed is that we see long wait times again in the public system. What can we start to do now to help mitigate that? Because my greatest fear is if you look at, we know waiting times have blown out, but they're actually we're no longer competing just for surgery time. We're now competing against knee reconstructions, hip replacements. How do we make sure that the system understands the critical role reconstruction plays in helping a woman return to a new normal for herself or not return, but find a new normal within what is going to be a very competitive financial health care system?

Dorothy Keefe [00:34:30] Yes, I think that's a really good question. So of course, cancer isn't the only chronic disease that's been impacted by COVID, and the recovery will have to take everything into account. But I think I think what you have to do is it's all about communication. So it's messaging, communicating with the powers that be. And I think it's about not going for black or white, but going for shades of grey. So, for example, I wouldn't be saying all reconstructions must be done ahead of all knees or we must only do hips and no ankles or whatever it is. I think what we've got to go for is a balanced portfolio with universal health coverage is universal across the community. But also of all the things that that the health system provides and the justification for them is more than just a physical or more than just a psychological issue. So I think what it is that we have to do is weave some sort of balance into it. And I think if you had that conversation with a CEO of a local health network and talked about how, you know, we absolutely understood that a certain number of knees and a certain of hips and a certain number of ankles needed to be done, as well as a set number of reconstructions and a certain number of other things, I think they would get that in terms of what the benefits, the global health benefits are for the person undergoing those treatments. And anyway, you know, if you don't do any reconstructions and you only do orthopaedics, there won't be enough orthopaedic surgeons to do all of that anyway. So you have to always have that balance, and the theatre equipment won't be right and all of those other things. So I think it's buying into the balance is the issue.

Kirsten Pilatti [00:36:22] I think also really helping to utilise some of those silver linings where we've seen public private partnerships work so effectively at a time of need, that maybe this is another chance for us to look at potential solutions with government. To help with, you know, really deal with some of that backlog that is going to be inevitable.

Dorothy Keefe [00:36:45] I think that's true. I think everybody was surprised. I think the public and private health system surprised themselves when it happened so seamlessly.

Kirsten Pilatti [00:36:56] So, Dorothy, thank you for your time. And may we continue to always hold the systems to account and to make it better for the people tomorrow and better every day. That's really what we want to do. And I want to thank you for your leadership. And as I said, including BCNA always in your work.

Dorothy Keefe [00:37:22] Thank you very much.

Kirsten Pilatti [00:37:23] This podcast was empowered by Red Energy, and we thank Red Energy for their ongoing support of Breast Cancer Network Australia. Our My Journey online tool has a hub of resources about COVID-19, including information on topics such as telehealth, mental health, as well as support relevant to a breast cancer diagnosis. To sign up to access the My Journey online tool visit my journey dot org dot au. If you are a health professional, we'd also encourage you to join up and refer all of your patients to information that's curated and specifically designed for their type of breast cancer. A reminder that if you have any specific concerns about COVID-19 and breast cancer to speak directly with your health professional. Thanks for being Upfront with us.