Yeah. Yes. Jeff Liu from Princess Margaret Cancer Center in Toronto. I'm very curious in knowing how, in particular places like Australia and other places where there's a lot of travel that's involved, how do you deal with the personnel issues about hiring people that are willing to travel so far? Is that an issue or do you hire different people at different times? And that goes to any of the speakers, but particularly I'm interested in the ones in which there's a lot of traveling. I might take that one first. We have a dedicated crew that work sort of shifts on and off, so often they'll do a two weeks on, two weeks off. The most important people aren't the doctors or the nurses or the radiographers, it's actually the drivers because they're the ones responsible for getting the machinery around and often the radiographers or the doctors can fly in because even though we don't have a lot of road infrastructure in some of these places, you can always take a small plane, whereas the truck can't do that. And so the drivers really is the most important part to make sure we have a good crew. And they love it because they get to, I think they're just naturally inclined to be driving long distances in the outback. So it's really important to make sure that the staff, that they really feel like that suits them. Yeah. I'm sorry, we may be having many more questions to come, but we have limited time, so we expect we may not be able to answer all the questions, discuss them all, so may I ask one in the microphone in the front? Yes, hi. Greg Mogul. I'm a radiologist with 4D Medical. The incidental findings are a huge issue for lung cancer screening generally with a lack of standardization. I wonder how in mobile screening you manage incidental findings. I mean, I know Dr. Jones mentioned repeatedly, you know, the significance of pneumoconiosis, but other findings as well. Are there unique strategies in a mobile population for managing incidental findings in the lungs? Well, Ricardo's volunteered me, so I'll take it. Yeah, it's a big topic, isn't it, that we're discussing? Personally, I don't think for us, because we don't have the doctors and so on on the truck, the results come back and get reported as per any scan. So for me, the mobile aspect isn't hugely significant. It's the bigger question of how you handle incidental findings. I think you need a whole session on that, really. But in the UK, we're trying to unify it. There is, hopefully coming very soon, a national sort of more standardized how we should all treat incidental findings. We seem to be going down the route of category, you know, expected, unexpected, so emphysema, corneal, and then really sort of unexpected breast lesions, renal lesions. So it's all trying to protocolize things, use as much evidence as we can. And I suspect over coming years in this symposium, that will be things we all need to learn from each other. But the mobile part doesn't make a huge difference for us. Well, let me explain why I volunteer here, because of a preliminary background. As a surgeon, to deal with the incidental findings, it's to decide to do biopsies or invasive procedures. And we do this in the multidisciplinary board. All the image goes to the cloud. But it's important to have a follow-up for physicians. And different of you are saying, in Australia, we don't fly the physicians over different places. But we don't send physicians with the mobile CAT scan unit. All the work is done by the nurses, by the technical radiologists, and the patient interview. All the data is collected. All the people, all the participants that have no findings, as I showed here, we see together. And those with incidental findings that the question is about, then we schedule a consultation with physicians in specific times after weeks or a month after the CAT scan is done. So we have a facility, a hospital, or the community will provide a room with a bed. And I think the physician will need to interview and do the physical. I think I'll just say one comment about the difference between mobile and non-mobile screening. Is that you need to, if you need to do a contrast CT, or you need to do some further evaluation on something, the classic example is, oh, I think you might have a renal mass on this non-contrast study. We need to get them back to that, have that contrast CT while the truck's in town. And so that means that that turnaround pressure on the report has to be a bit higher. And that's probably the main difference between mobile and non-mobile for us. Hi. My name is Lucia Viola. I'm a pulmonologist in Colombia, South America. And the first question is for Ricardo. How do you deal with pulmonary infections in our countries? This is a big deal. And a question for Rabal is, how do you deal with the tobacco cessation in this mobile scenario? And how do you connect this with a follow-up for the patient trying to leave the dependence? Thank you. Thank you, Lucia. I know we face the same challenges in Colombia and Brazil. We have in the public system tests for TB and everything. Of course, I think the major problem is if the patient, when they realize that you are asking for symptoms and you are in a program for preventive, if they underestimate the symptoms or if they don't say the symptoms because they know that it's a preventive care unit and they will not get the CAT scan if they say they are very symptomatic, they should go to the hospital due to the conventional pathway. But the patient that we see with those findings, the pulmonary physician will interview and just send to the tests. We have consolidated the data yet. I don't know how many cases like that one I had in the mobile unit, but I hope that the next months I can consolidate and tell better what was the follow-up and the real diagnosis of tuberculosis. Because this is a public problem, right? If the person has tuberculosis and it's still infected other people, we need to be concerned of that, of course. I can keep it brief for your question, Lucia. So our nurses are trained to do sort of informed decision-making. We have leaflets and so on to discuss pros and cons of screening before they have the scan to address those questions. In terms of follow-up, because we don't have the distance, the truck does go back around. So if you're due three-month scans, we come back to the same area so you can have the scans. If you're due a 12-month scan, we come back for convenience. And I didn't mention in the talk, but our adherence rates are very good. So 80% to 90% most of the time, we have a team to chase people up. So we don't lose people that often. Sorry, maybe in the interest of time, maybe we can only take one more question. And from the microphone in front, sorry about for the colleagues behind. Doug Wood from University of Washington in Seattle. A question for Dr. Jones. I worked for a time with the Royal Flying Doctors in Alice Springs. So I think most people in the room don't have an idea about how remote the remote is that you're talking about. And my question relates to, where is the line of return on investment for enough people to go? I know you did it for Dr. Bellotta and Dr. Salas Santos, but I know how few people are in the places that you're going. Where's the trade-off where, as harsh as it seems, that it's worth putting the resources to a small region that has very few people to screen? Yeah, that's a great question. So people say, well, how do you fund this? And we say, well, we don't rely on donations or on benevolent societies. What we actually say is, these people deserve the same amount of care as everybody else. And so we access the exact same nationally-funded reimbursement schemes as everybody else. It is way cheaper for the local health districts in those areas to have the truck come out than it is to fly patients everywhere. So there is always an incentive for the local health districts to have the truck come out. And so they will guarantee a certain amount of work per day. And if we don't have the number of patients come in, they will fund that. But the important part here is, we find that not only does it save money for the local health districts in these areas, patients who would not normally have come in under any circumstances get intrigued because they say, what is this massive piece of machinery doing in our main street? And everybody comes in for a chat, for a bit of a sticky beak. And then the next thing you know, they've had a heart check, they're on the treadmill, they've been given a referral, and they walk off thinking they've had a great service. Really important to recognise that these people also deserve access to care. And once we use that as an underpinning principle, the return on investment is actually far more than the same amount of resource that we put into a metropolitan area where those people already have access. So really important. I think it's not just about the lung cancer screening or about the dust-exposed disease. It's finding out all of the diseases in all of the patients and finding out, you know, do you have heart disease? Do you actually have a risk for a stroke? And that's why we provide more of a holistic service on the truck than just CT or X-ray. But I agree, it's really remote out there. Thank you. So in the interest of time, we have to move on to...

mobile healthcare

remote areas

incidental findings

patient follow-up

healthcare delivery