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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme No. 7. - Lung Cancer and Smoking
RADIO 4
TUESDAY 19/06/07 2100-2130
PRESENTER:
MARK PORTER
CONTRIBUTORS:
SAM JANES
PAUL CAVANAGH
ALEX BOBAK
PAUL JENKINS
PRODUCER:
JOHN WATKINS
NOT CHECKED AS BROADCASTbr />
PORTER
Hello. Today's programme is all about lung cancer. More British men and women die from cancer of the lung than any other type. Last year it accounted for one in four of all deaths from cancer in men - and one in five in women.
Lung cancer exacts such a large toll because it is both common, and difficult to treat. By the time most cases are diagnosed they are incurable. So could earlier detection using screening help?
I'll be visiting one of a growing number of private clinics that offer CT scans to the worried well. But does screening actually work. And if so, who should be scanned and when?
Treatment may not be as effective as for some other forms of cancer, and screening controversial, but there is no doubt about the value of preventative measures. Most, but not all, cases of lung cancer occur in smokers, and initiatives to encourage people not to smoke - or to give up if they do - are currently our best defence against the disease.
As of July 1st, smoking will banned in enclosed public spaces throughout England - a move the Government hopes will encourage as many as 600,000 people to quit. And later on I will be finding out what the NHS can do to help them - including a look at the latest stop smoking drug, heralded as the most effective aid to quitting available to date.
My guest today is Dr Sam Janes, he's senior lecturer and honorary consultant at University College Hospital.
Sam, as a physician with a special interest in lung cancer, you must be very pleased to see this ban coming in?
JANES
Absolutely, this is really fantastic for Britain because for the first time we really have a good chance of reducing the number of smokers in this country. It's thought that probably around 8 out of 10 lung cancers are due to smoking. That of course leaves two that aren't and some of those may actually be due to passive smoking. So overall smoking probably accounts for around 85% of lung cancers.
PORTER
Let's quantify those risks and look at how strong the link is between smoking and cancer. I mean assuming somebody smokes 20 cigarettes a day for 20 or more years how likely are they to get lung cancer, it's actually quite common isn't it?
JANES
Very, I mean it's thought that probably more than 1 in 10 smokers will develop lung cancer, of course others can develop other cancers or other lung diseases. One thing that's very interesting is if you manage to give up smoking what effect that has on your life expectancy. So a 45 year old that smokes perhaps 20 cigarettes a day if they were to give up smoking they would then expect to live on average seven or eight years longer.
PORTER
Because one of the things I often see in clinical practice you know when you're trying to encourage people say in their mid-40s to stop smoking - well you know I've been smoking for 25 years I've done the damage - is that the case with lung cancer as well, have you - have the toxins and the carcinogens in the cigarette smoke already done their harm?
JANES
It is true to a certain extent that they will have done some harm but if you do manage to give up, if you can give up after 10 years actually your risk of lung cancer returns back to normal. So you know you must try and give up but giving up early is a good idea.
PORTER
And what about passive smoking, you know any non-smoker will tell you if you go to a restaurant or bar inhaling other people's smoke is unpleasant, but is there actually a tangible risk of them developing lung cancer as a result of that?
JANES
Yes there really is, there's over 50 studies now that have looked at passive smoking and lung cancer and it's thought that probably around a thousand people a year in the UK will die from lung cancer from passive smoking.
PORTER
Are any particular group more susceptible to lung cancer, are there are group of people who really shouldn't smoke or is it just that you know it can cause lung cancer in anyone?
JANES
It's been very hard for us so far to try and tie down who are the people that develop lung cancer as indeed other sort of diseases from smoking, like emphysema, but it does seem that certain families, for example, are slightly more prone, so if you had a father that smoked and developed lung cancer then perhaps you are - well you are around twice as likely to develop cancer as other people.
PORTER
And that's assuming his illness didn't put you off.
Well the ban on smoking in enclosed public places comes into force in England in less than two weeks, but similar legislation has already been in place in a number of other countries - including Ireland, Scotland and Wales. But what sort of impact has it had?
The Irish ban on smoking in the workplace - which includes bars, pubs and clubs - came in to force in March 2004. Dr Paul Cavanagh is from the Department of Health and Children.
CAVANAGH
The smoke free workplace legislation in Ireland was implemented as a measure to protect workers against the health effects of second-hand tobacco smoke. Of course it does also have some wider benefit which is to denormalise tobacco smoking and bring about a change which means that people will be less likely to start smoking and that people will be more likely to quit smoking, so it creates a supportive environment which helps people make healthy choices.
PORTER
Three years on do you have any evidence of any tangible benefits, do we know if perhaps more smokers have tried to quit?
CAVANAGH
Yeah well without a doubt this legislation has been a huge success in Ireland. A study of bar workers across the island of Ireland showed that workers in the south of Ireland they enjoyed a reduction in exposure to second-hand smoke and an improvement in respiratory symptoms following the implementation of this legislation. So that's the success on the first front which is in terms of actually protecting the smokers. The second area in which the legislation was successful then was bringing about this societal change, this denormalisaton of tobacco smoke. I mean I think it's very important for us to remember that tobacco isn't a normal product, this is a product which when it's used exactly as the manufacturers design it to be used kills people and kills those people around them. So by implementing this legislation the government of Ireland sent out a very strong signal which said tobacco smoking isn't normal.
PORTER
Do you think that's a message that smokers have taken on board?
CAVANAGH
Oh very much so and in fact we have strong evidence to support that. You know we found that in the year 2004, the year in which we implemented this legislation, the prevalence of smoking in Ireland reduced from 25% to 23% and that's had huge benefits in terms of the public's health. We found a survey that was undertaken following the implementation of this legislation found that among smokers 46% said that they thought that this law was going to help them quit and of those who had quit 80% said that they thought the law helped them to do that and a further 88% said that they thought that this law was going to help them stay stopped.
PORTER
One of the concerns amongst doctors here in England has been that if we outlaw smoking in public places like bars and clubs, for instance, that smokers will be more inclined to smoke at home and possibly in front of their family - any evidence that that's happened?
CAVANAGH
In fact in Ireland we found that the opposite was true. A survey that was undertaken before and after implementation of this legislation showed a proportion of homes in Ireland that had implemented a similar ban on indoor smoking actually rose following the legislation and this is consistent with studies from other countries such as Australia which showed a similar benefit. So really in fact smoke-free workplace legislation is actually an important policy instrument to bring about smoke-free homes.
PORTER
Well given your own experiences over in Ireland do you think England's been a little slow to join the party?
CAVANAGH
Oh not at all, I mean I think your government has really led the way in terms of being highly effective in using a whole range of policy interventions to try and combat tobacco use in the general population, measures such as pricing, education, advertising bans and smoking cessation. The way that I would look on this is that tobacco really is a global epidemic and countries have a lot to learn from each other in tackling this. I think we in Ireland are very proud of the fact that we've been European leaders in this area. But I think we're also pleased to be able to share the story of our success with other countries and really lead the way for them to implement and to observe similar success.
PORTER
Dr Paul Kavanagh talking to me earlier from Dublin.
You are listening to Case Notes. I am Dr Mark Porter and I am discussing lung cancer with my guest Dr Sam Janes.
Sam, presumably it will be many years before we can measure any impact of the ban on lung cancer rates here in the UK.
JANES
Yes you're right. The lung cancer develops over many, many years and often patients that present to us with a lung cancer will have had that tumour growing inside them for perhaps 10 or even 15 years before they come to us. So not only do you have the sort of lag time of these people, hopefully lower numbers smoking in the future, but also the lag time of all these tumours actually growing.
PORTER
So it could be 20 or 30 years before we see any benefit?
JANES
It may well be.
PORTER
But from what we know already from the epidemiology, from the studies that have been done, if we can persuade - as happened in Ireland, I mean something like 1 in 10 of their smokers appear to have given up, that's going to have a major knock on effect?
JANES
I mean that's absolutely fantastic isn't it, that probably sort of mean tens of thousands of people will have given up smoking in Ireland and each of those people should, in theory, gain seven or eight years of life.
PORTER
Well the ban may encourage smokers to quit, but sadly most won't succeed. Giving up smoking is an uphill struggle - even for the most committed quitter. Dr Alex Bobak is a GP in Wandsworth with a special interest in smoking cessation.
BOBAK
We used to handle it by decibels, the more decibels you gave the better of chance of stopping, well actually that doesn't work, you know frightening people to stopping is just not effective. We're dealing with the most powerful addiction around, more addictive than injected heroin or snorted cocaine. These people need help, they need support and they need treatments and the combination of those things can increase your chance by ten fold if you do it the right way with support and treatments.
PORTER
Let's look at those figures. If you take the average person who decides to quit alone at home, using nothing but their willpower, what are their chances of success compared to someone who might go to the state of the art clinic where they get the best support and the latest drug treatments?
BOBAK
The people who do it by themselves, which is sadly still the majority of quit attempts, have a 2 - 3% long term success rate.
PORTER
And by long term you mean ...
BOBAK
A year. The standard is a year because if you get to a year there's a very good chance that you can stay stopped as long as you don't lapse.
PORTER
So on their own 98 out of 100 of people who quit will be back on the cigarettes within 12 months, compared to?
BOBAK
Well support alone, from someone trained in helping you stop smoking, can get your rates to 10-15%. But if you add treatments you can double that to 20-30 or even more percent and that's a lot for a very powerful addiction.
PORTER
Healthcare assistant and stop smoking advisor Julie James is the person who provides that essential support and expert input at Alex Bobak's clinics.
Julie, a lot of the clients that come and see you will have smoked for many years, what suddenly makes them want to give up?
JAMES
It could be a number of reasons, sometimes it could be advice from the GP, it could be if they've had a health problem, sometimes it's word of mouth - if a friend of theirs has managed to quit then it sort of gives them a bit of an incentive.
PORTER
You've now got lots of different ways of helping people, all the different forms of nicotine replacement therapy, the new drugs, how do you when you're talking to a patient decide on which approach might be best for them?
JAMES
It can be any reason, it could be age, it could be that some people don't like to take tablets, some people you feel that they have a skin reaction - so a patch wouldn't be suitable. What I normally do is get all my bits and pieces out on the table and we just go through them and I leave it up to the client to decide. Some of the new drugs you need to be over 18.
PORTER
What's the youngest client you've seen?
JAMES
At the moment I've got a 16 year old, obviously came here asking for the new treatment but unfortunately you need to be 18 but we've took another approach and she actually likes chewing gum, so we've gone done the route of the nicotine gum.
PORTER
And how do you know that they're not cheating?
JAMES
We have a machine to detect carbon monoxide poisoning. I can do this on yourself today. If you say to me no I've not had a cigarette and you blow into the machine and the machine blows above the reading of five and the machine is red I know that you've had a cigarette.
PORTER
Right, well let's see how I do on this then. So basically it's a small little electronic device that you just blow into.
JAMES
It's called a CO monitor. Basically what happens is I'll talk you through it, I'll switch the machine on...
PORTER
So it's measuring carbon monoxide which is a by-product of the burning in the cigarette?
JAMES
That's right. You need to hold your breath, deep breath in and hold it, when the machine goes to zero you've got to seal your lips around the tube and then blow all the air out of your lungs till you can't blow anymore.
Well done, what's your reading?
PORTER
Three.
JAMES
That's brilliant and green. So that's healthy.
PORTER
Shouldn't that be more though?
JAMES
Not necessarily, because obviously ...
PORTER
That's Wandsworth air is it?
JAMES
Yes, yes.
PORTER
So if I'd have had a cigarette, if I was trying to give up smoking and I'd had a cigarette, how, you know ...
JAMES
Say you'd had one cigarette today...
PORTER
Right but if I had one last night, I'd been to the pub and had one ...
JAMES
Normally it would show up as an amber.
PORTER
So you'd still pick them up, yeah.
RUMMERY
My name is Rita Rummery. I did try to stop smoking long since but then what happened is that I lost my job and I had £400 a month less and that means if you're a pensioner.
PORTER
How much were you spending on cigarettes then?
RUMMERY
A hundred and twenty pounds a month.
PORTER
So it was the finances that pushed you.
RUMMERY
The finances and also the invitation I had to come and see the doctor for something else, I can't remember, and you know there was an advert if you want to give up smoking it's a good time, you can meet Julietta and that's what I did and she convinced me that I should stop smoking.
PORTER
And what technique did you use?
RUMMERY
Inhalers.
PORTER
A nicotine inhalator, it looks like a plastic cigarette effectively.
RUMMERY
Yeah that's what it is, I don't need the nicotine anymore but this kind of gives me something to hold.
PORTER
You put a little cartridge in there and it gives you some nicotine, but you like handling it as well do you?
RUMMERY
Yeah, handle it more than actually taking the nicotine out of it.
PORTER
And how long have you been smoke-free now?
RUMMERY
Two years in 9th December 2005.
PORTER
But you still carry this round with you?
RUMMERY
Yes, gives me company, you know it gives me a kind of - not security but a friend, constant friend.
DETMER
My name is Anne Detmer and I gave up because my health was really suffering through smoking.
PORTER
Like Rita, Anne started smoking in her teens and was soon on 60 a day. She tried to quit using various methods but nothing worked until she joined a trial of the drug Champix - a new treatment with a dual action that works to both stimulate and block nicotine receptors in the brain. Put simply, the blocking action prevents smokers from getting a hit when they smoke, and the mild stimulatory action helps prevent withdrawal symptoms.
DETMER
I was very excited by it because it was completely different to anything else that I had tried What was fascinating was to be told that I would actually take it for a week before my official quit day which is very different from anything else, I mean everything you start by quitting is the theory. And I had no idea how it was going to work but I did what I was told - I started to take the drug. And after about two or three days I looked in the ashtray one day, now my ashtrays used to be piled high, absolutely piled high, and I saw that it was a great deal less in height than it normally was and not only that but cigarettes were half smoked. Now I used to smoke absolutely up to the very last possible moment on a cigarette, so that something had been making me put that cigarette out halfway through. I still had about four days to go till my quit day and I actually found that whole experience very exciting because it gave me hope that this was a method that was going to work for me.
PORTER
And once you'd stopped completely did it help with the cravings and the withdrawal?
DETMER
Yes it did, it didn't do it without me, you have to be committed - I was an addict - and I used to have physical pain when I used to try and stop smoking, it was like insects crawling on my skin, it was dreadful. So to have this support was just astounding.
PORTER
How long did you take the drug for?
DETMER
Well I took it for three months.
PORTER
And then I suppose the next hurdle is coming off the drug, was that a problem?
DETMER
I was apprehensive because of course I knew that this particular pill was working. I learnt a bit about how everything works and I learnt that those receptors in the brain do actually naturally start to give up after three months. And so when I did stop the drug I was okay.
PORTER
Anne Detmer talking to me at GP Alex Bobak's surgery in West London.
Dr Sam Janes, early trials suggest that Champix, the drug that Anne was taking, is the most effective drug we have ever had for helping smokers quit. Do you think that will prove to be the case in the real world outside of the environment of clinical trials?
JANES
I think so, I mean I really like the way this drug works, it reduces your craving, reduces your pleasure of smoking, it should really make an impact and actually many of the trials - there are three big trials on this drug - most of the patients had actually already had nicotine replacement therapy before they even got into the trial and failed on that. So they've taken on a tough bunch of patients with this drug.
PORTER
Because of people who've tried - most smokers have tried before haven't they - I always think of the old adage that you hear - it's dead easy giving up doctor I've done it loads of times.
JANES
Absolutely. It's incredibly difficult to give up smoking. If you try by yourself you have around a 1 in 20 chance of giving up smoking over a year. If you try with the assistance of this new drug - Champix - you have about a one in five chance of giving over a year.
PORTER
It's a big difference.
JANES
That's a big difference.
PORTER
A lot of people don't like taking drugs though, what about side effects?
JANES
The side effects seem pretty reasonable, so there was a report of around 2% of patients reporting nausea ...
PORTER
So 1 in 50 felt sick.
JANES
Absolutely, and hardly any of those actually stopped taking the drug. So it seems to be tolerated very well.
PORTER
And it's just been given the thumbs by the National Institute for Healthcare and Clinical Excellence - NICE - so it should be available at a surgery near you.
JANES
Absolutely.
PORTER
Well despite the advent of new treatments like Champix, and stop-smoking clinics, lots of smokers never give up - and even those who do often end up smoking for decades before they succeed.
And of the myriad smoking related illnesses they risk, it's lung cancer that tends to worry smokers - both past and present - the most. A worry that is driving an increasing number of them to pay for private screening tests. Screening that uses CT scans to pick up suspicious growths in their lungs long before they are big enough to be seen on a conventional chest X-ray, or cause symptoms.
I went along to the European Scanning Centre in Harley Street to find out what's involved. Consultant physician Dr Paul Jenkins is the centre's Medical Director.
JENKINS
It's a non-invasive procedure and a relatively quick procedure. The patient lies on the scanning couch and it takes about 5-10 minutes.
PORTER
So what sort of abnormalities might you pick up if you're doing a screening test on let's say someone who's been smoking for 20 years what would you be looking for?
JENKINS
The patient and we are most concerned about detecting cancer. So that's one aspect. But I think just as importantly is the signs of long term damage to the lungs - such as emphysema or chronic airways disease...
PORTER
Smoker's lung.
JENKINS
Smoker's lung, yes. And that's often very useful to the individual in seeing the damage that they're causing to themselves and as an aid to giving up.
PORTER
As a general rule how much earlier might you pick up a suspicious lump using a CT scan than you would perhaps using conventional chest x-rays, is it possible to say?
JENKINS
Well this is an area of debate and ongoing research. But a recent trial, the so-called Early Lung Cancer Action Project, published recently in the New England Journal of Medicine, showed that detecting the cancers early vastly improved survival.
PORTER
Okay, well let's have a look at some of the things that might raise alarm bells for you, you've got some CTs here.
JENKINS
So this is a cross-sectional CT, so what I call the salami slice from top to back.
PORTER
Literally cutting the patient through the chest horizontally and then you're looking down on their thorax.
JENKINS
We're looking through their thorax and you can see the immense fantastic detail with this looking at any signs of the airways disease....
PORTER
And those airways, they're the little white things are the ...
JENKINS
These are the bronchioles or the air tubes and these are the sacks of air. And normally you could say that this should be like a lump of cheddar and with airways disease it becomes gruyere or Swiss Emmental, big holes appear. The areas we're also interested in are little nodules, such as this, which could be an early cancer.
PORTER
And how big is that?
JENKINS
That's about three to four millimetres in size.
PORTER
And it basically looks like a large white spot, so it's smaller than a baked bean, can you tell what it is just by looking?
JENKINS
No and that's what the critics of CT screening will say, is that the majority of these will be or are likely to be benign. And just looking at it you can't say what it is.
PORTER
And on what proportion of people that you're seeing here might you pick up some form of nodule?
JENKINS
It depends slightly on the patient group but probably overall around 8-10% might have a nodule.
PORTER
So as many as 1 in 10. But most of those would be ...
JENKINS
Most of those would be benign and needs no follow up.
PORTER
Well let's look at another example here.
JENKINS
Another one, this is another nodule you can see which is ...
PORTER
A bit bigger.
JENKINS
... bigger, approximately about a centimetre. And this one you can see would give cause for concern, this is greater than one and half centimetres in size.
PORTER
And that to my untrained eye looks slightly different from the others, I mean a. it's obviously bigger but b. it looks like it's sort of spreading out a little bit more.
JENKINS
Yes that's exactly right and that is a warning sign when it starts looking slightly spiculated, we say, or with irregular edges and that makes one think more that it is a cancer.
PORTER
So someone in whom you found this you would refer them immediately to be looked at by - and the only way they're going to find out what it is, is probably to remove that?
JENKINS
Well there are two ways. I mean we would refer to a chest specialist and the chest specialist might say actually you should have this surgically removed or they might say no, we think we could look at that with a telescopic examination, the bronchoscopy, and then take a little biopsy of it and try and see if that was ...
PORTER
But that one would be immediately referred on, what about these ones with the smaller ones that you're not sure about?
JENKINS
Depending on the certain characteristics of them anything from six months to a year.
PORTER
And you'd follow up. And if it's the same size?
JENKINS
Then we can dismiss it confidently and say if it hasn't grown in a year then this is benign, end of story.
PORTER
Paul Jenkins from the European Scanning Centre.
Dr Sam Janes. I know this is a controversial area - on the one hand supporters of CT screening say that it picks up cancers early and that must save lives. On the other hand sceptics say that it can do more harm than good and causes unnecessary anxiety, and even unnecessary surgery, in the majority of people who have nothing but innocent benign things that'll never bother them.
Presumably, as with most medical controversies, the answer lies somewhere between the two?
JANES
I think so. We are desperate for lung cancer screening to work. This year we've had two trials released, the first really was fantastic and suggested that their lung cancer patients that they screened they would pick up 85% of their lung cancers very early indeed and all those patients could have operations to remove their cancers.
PORTER
Potentially curative.
JANES
Potentially curative, they estimated that 90% of their patients would live 10 years, and that is unheard of for lung cancer. On the other hand another study has come out showing very similar results that they found a lot of early lung cancers, they did a lot of operating, took out these lung cancers but interestingly they then examined in a mathematical model how many lung cancers they would have expected to treat and how many lung cancers they would have expected to die over the same time and interestingly in the study 38 patients died and 38 patients were expected to die. So this suggests that they were diagnosing three times as many lung cancers, performing 10 times as many operations but not saving any lives.
PORTER
Now this is hard for people to understand really because it just seems so logical that if you pick a cancer up early and you go in there aggressively that you must be saving people's lives but actually what you might just be doing, particularly in cancers with a long lead in time, is just diagnosing them much earlier so their survival appears longer?
JANES
Absolutely and it does appear from the second study that perhaps two thirds of the lung cancers the patients would have just lived with and died of something else.
PORTER
So I mean but people are still going to want to know if their lungs are clear and there still might be some value for the individual, I mean we just don't have the evidence at the moment is what you're saying. But if you had to say to somebody yes I think it might be worth you going forward for screening or you should definitely not, where do you draw the cut off? Presumably a non-smoker in his 30s is wasting his time going for screening?
JANES
Absolutely and there you would just going to bring up all the funny lumps and bumps that you find in your lung ...
PORTER
Cause more harm than good.
JANES
Absolutely. You find 10 times as many benign lumps in the lung as you do cancerous lumps and that produces an enormous amount of anxiety for people. I think we're going to have to try and work out who benefits from CT screening and that is probably going to be people with a lengthy history of smoking.
PORTER
By lengthy, from a cancer physicians point of view, you'd regard that as?
JANES
Probably 20 a day for perhaps more than 30 years. All the trials so far have been in an age group over 45 and actually what we also know is that if you suffer from bronchitis or some sort of lung disease produced by smoking other than lung cancer you're also more likely to develop lung cancer.
PORTER
So you might consider going in for screening earlier, although the case remains unproven is what you're saying?
JANES
Absolutely.
PORTER
Work in progress. We heard there from Paul Jenkins that people are referred with early suspicious lumps, what can you do for them, they come and see somebody like you or one of your colleagues, how can we treat lung cancer and what are the chances of treating it successfully?
JANES
Well from the CT studies that have been produced you can apparently treat these things fantastically successfully with surgery. And it's always surgery that we try to push our patients towards. Unfortunately in this country currently there's a very low percentage of patients that can have surgery because lung cancer tends to present late and it's spread beyond where the surgeon can get to.
PORTER
So by the time the majority of cases are diagnosed it's too late?
JANES
Too late for surgery, of course there are other therapies but they're not as good as surgery.
PORTER
And they're presumably not curative in most cases, are they controlling the disease rather than getting rid of it?
JANES
Yes. So radiotherapy can be curative in some lesions but otherwise they tend to be palliative.
PORTER
Well let's put those screening figures we were talking about in terms of survival in context. The average case that arrives in the UK at the moment without screening the survival prospects are what?
JANES
It's around a 1 in 20 people live five years, so that's very different ...
PORTER
... compared to many other cancers. And that's not a figure that's changed very much in recent times?
JANES
It's been pretty well the same for the last 30 years.
PORTER
Anything new on the horizon?
JANES
I mean there have been two new drugs which have shown some limited success in lung cancer, unfortunately they've currently failed those sort of NICE ...
PORTER
Approval tests.
JANES
... approval tests but it maybe that we're just not choosing our population right.
PORTER
But to be fair they may improve the outlook for some people but they're not revolutionising the treatment of lung cancer, we're still waiting for that.
JANES
No, I mean it seems to produce perhaps a two, three, four months survival.
PORTER
I am afraid that is all we have time for. Dr Sam Janes, thank you very much.
This is the last in the current series of Case Notes but we will be back after the summer so if you have any subjects that you think we should be covering then please do get in touch - either via the Contact Us facility on the Case Notes website at bbc.co.uk/radio4 or via the Action Line on 0800 044 044. Until then, good bye.
ENDS
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