Teenage Cancer Trust
The final item of business is a members’ business debate on motion S4M-07630, in the name of Aileen McLeod, on supporting Teenage Cancer Trust’s education programme. The debate will be concluded without any question being put.
Motion debated,
That the Parliament recognises the importance of early diagnosis of cancer in Scotland’s young people; acknowledges what it sees as the key role of Teenage Cancer Trust’s education programme and its innovative and unique partnership with the Detect Cancer Early Programme in educating young people in South Scotland and across the country about cancer; notes that Teenage Cancer Action Week takes place across the UK from 14 to 20 October 2013; understands that the key aim of the week is to raise awareness of the five most common signs of cancer in 13 to 24-year-olds and for this knowledge to be shared among family and friends, and commends Teenage Cancer Trust on its efforts to raise awareness of cancer among young people, educating them on the importance of early diagnosis and improving the wellbeing of young people who are diagnosed with the condition.
17:25
I am delighted to lead this debate in support of the Teenage Cancer Trust education programme. I thank the members who signed the motion and made the debate possible, and I thank those who will speak in such an important debate.
I pay tribute to Dawn Crosby, Caroline Brocklehurst, Iona MacMillan and Rosanna Innes, from the Teenage Cancer Trust, who are in the public gallery. Their dedication and commitment to helping to improve the lives of teenagers and young people in Scotland who have cancer deserve our recognition and thanks. Their enthusiasm for what they do makes such a difference to the lives of the young people whom they support.
I first heard about the Teenage Cancer Trust in 2000, when Roger Daltrey, of The Who, organised the first fundraising concert for the trust at the Royal Albert hall. I thought then that at last there was an organisation that was dedicated to supporting young people with cancer and helping them to deal with what is an extremely traumatic and life-changing event.
Since its inception in 1990, when its first teenage cancer unit opened at the Middlesex hospital in London, the trust has gone on to fund, develop and open 25 units across the United Kingdom. It currently has four operational units in Scotland, which provide 18 beds across four hospitals in Edinburgh and Glasgow. It also funds youth support co-ordinators, who make a huge difference to young cancer patients’ quality of life, by helping them to share their experiences.
In April I visited the Teenage Cancer Trust unit at the Beatson west of Scotland cancer centre, at Gartnavel hospital. It was an opportunity for me to learn about the services that are available to young people with cancer and to meet families and hear about their experiences at first hand, as well as meeting the dedicated nursing and clinical staff whose care and support is, without doubt, second to none.
The visit was all the more poignant for me because I am a teenage cancer survivor, and I know what it is like to be that young person, who just wants to be like any normal teenager. I know how lonely I felt when I was not able to talk to anyone who was the same age as I was and who was going through the same treatment. I was so impressed by the unit, and I am so glad that young people who are fighting cancer have such a place to support them. What is so important about the unit is that it brings our young people together, where they can be treated by specialists in teenage cancer, and that it enables the young people to be themselves first and cancer patients second.
For young people, the trauma of diagnosis and harsh chemotherapy—with all that that means for hair loss and fertility—happens at the worst possible time, just when they are trying to find out who they are. To be able to go through their treatment with young people their own age and not on their own, and to be able—when they feel up to it—to hang out together, playing pool, listening to music, watching DVDs and playing computer games, can make such a difference to the whole experience.
It was at the unit that I met Amy Callaghan, who is in the gallery, and Amy Quinn, who unfortunately cannot be here. We have all read Amy Quinn’s letter about her personal journey with cancer. I thank Amy Callaghan, Mairead MacLeod, Emma Scullion, Angela Colquhoun and Luke Coulter for meeting me that afternoon, and I thank Amy Quinn in particular for sharing her experiences with us, which I know took a lot of courage.
I think that all members will agree that Amy Quinn’s story has made more impact than any report or policy statement could do. It was very much with her wishes in mind that I sought this debate, because we should do everything possible to ensure that other young people do not have to go through the lengthy journey of diagnosis that she experienced.
Teenagers and young adults with cancer are a particularly vulnerable group, with unique physical and emotional needs. As the trust said in its helpful briefing, cancer is the most common cause of non-accidental death in young people, and five-year survival rates remain lower in teenagers than in children.
Seven young people aged 13 to 24 are diagnosed with cancer every day in the United Kingdom, which is around 2,500 each year. In Scotland, an average of 203 teenagers and young adults are diagnosed with cancer each year while, across all age groups, two in five people in Scotland will be diagnosed with some form of cancer during their lifetime.
According to the trust, the signs of cancer in young people are often dismissed or misdiagnosed because they are similar to less harmful problems. Research that was carried out by the trust shows that 40 per cent of Scottish young people with cancer had to visit their general practitioner four times or more before their symptoms were taken seriously or they were referred to a specialist. Some of the difficulties can arise because young people do not always know when something is seriously wrong, take a while before they decide to seek medical advice or simply find it hard to talk to their GP and explain what is wrong.
All that contrasts worryingly with the universally acknowledged fact that swift early diagnosis and referral for specialist treatment is vital and has a positive effect on patient experience, potentially reducing the intensity and duration of the treatment; the scale of late effects; quality of life; and, in some cancers, survival itself. Therefore, we need to educate young people and health professionals about the ways in which cancer can present in teenagers in order to improve the speed and quality of diagnosis. Although cancer in that age group is rare, given the comparatively poor survival rates it is vital that we all know the five common signs so that further medical advice can be sought if there are ever concerns. Those signs include pain of all kinds, including headaches, stomach ache and pains in the legs or arms; unexplained lumps, bumps or swellings; extreme tiredness; significant weight loss; and changes in a mole.
To empower our young people to take control of their health, the trust plans to raise awareness of those five most common signs of cancer in our young people through its teenage cancer action week between 14 and 20 October. That will be actively promoted through schools, with a free education pack, as well as through social media, local GP surgeries and youth clubs. Members of the Scottish Parliament can help by sharing the information at our local community centres and surgeries.
Another route is through the trust’s pioneering education programme, which is raising awareness and providing advice about the signs of teenage cancer, cancer treatments and prevention, and healthy living. To date, the trust has worked with 95 schools in Scotland, reaching more than 11,000 students, and we know that its innovative approach works because research by the University of Stirling on the programme showed an increase in the number of cancer warning signs that teenagers recognised.
To help to ensure that education about and awareness of cancer continue to play a central role in early detection and diagnosis, the trust has been working in partnership with the Scottish Government’s detect cancer early programme. Since its launch in June by the Cabinet Secretary for Health and Wellbeing, Alex Neil, the programme has succeeded in recruiting 20 schools, double the number of secondary schools in Glasgow that were initially targeted. All the schools will be monitored to evaluate the impact of the educational programme on both pupils and their wider families. In total, more than 2,400 students and 295 parents/carers will be part of the programme, making the study the biggest health intervention scheme of its kind in Scotland. It will, I hope, mean that the next generation is not afraid to talk about cancer. In that regard, our young people have a key role to play in Scotland’s fight against cancer.
The Teenage Cancer Trust is working hard to improve the quality of life and chances of survival of teenagers and young people throughout Scotland, not least through its excellent education and awareness-raising programme. On 6 November, I will host a parliamentary reception with the trust at which it will launch a new report highlighting the scale of delayed diagnosis among young people with cancer in Scotland. Much work is being done, but more work still needs to be done to support our young people in their fight against cancer, ensuring that they have a clear care pathway that takes them forward to a life without cancer. I look forward to continuing to support the Teenage Cancer Trust in all that it does for Scotland’s young people with cancer.
17:34
I congratulate Aileen McLeod on lodging her motion and pay tribute to all the work that she has done, over the years, in this important area. I also congratulate the Teenage Cancer Trust for all the superb work that it has done. The education programme is the main topic of the debate but, as Aileen McLeod reminded us, the trust has also been involved in supporting and funding specialist units in national health service hospitals such as the Beatson, providing dedicated staff. We should remember that very important part of its work.
This evening we are concentrating on the trust’s work to educate young people and health professionals about cancer, in order to help improve the speed and quality of diagnosis. Early diagnosis is crucial for all cancers and it is a matter of particular concern that for teenagers and indeed children there is often a particular problem of late diagnosis. In fact, this is a problem in relation to children that several people have drawn to my attention in the past few weeks.
The programme that is provided by the Teenage Cancer Trust is extremely important. The trust offers a unique service that no other charity provides, in that it provides free outreach services to schools, clubs and youth associations. Between 2011 and 2012, for example, it visited as many as 95 schools, passing information to 11,000 young people.
In the teenage cancer action week, which will come up very shortly, the trust will focus on the five most common signs of cancer. The trust clearly has a very important role in communicating in the presence of teenagers, but it also has a wide range of accessible advice on its website. As the teenage cancer action week approaches, the trust has used the opportunity to invite young people on to its forum to share their stories and the challenges that they have faced.
The example of Amy Quinn has already been referred to and we are all very grateful to her for sending her letter to us. I do not have time to read out very much of her letter, but I noticed what she wrote towards the end of it:
“I told my doctor and she dismissed me as just being a grumpy teenager. Eventually she said she thought it might be a cyst”
that is an ovarian cyst
“but I disagreed. I told her I didn’t think a cyst would make me feel so weird all the time, but she wouldn’t listen.”
As the Teenage Cancer Trust points out, such dismissal of teenagers with cancer is not uncommon. In the case of Amy, after she persistently argued that she would require further help, she eventually succeeded in having the treatment that she needed. If it had not been for the advice given to her through the outreach scheme, this young woman might not have been so resolute in continuing to seek help. That is one example of the vital work that is done by the Teenage Cancer Trust.
We should also refer to wider services for teenage cancer patients in general. Before this debate, I read the cancer plan for children and young people, which is very commendable. In particular, it focuses on a managed service network—a particularly Scottish feature of the health service over the past decade or so—for teenage cancer. That is a very positive development, although it is a bit worrying that some of the key aims are not being met, such as equity of access to the best possible care and equity of access to clinical trials.
It is clear that there is room for improvement, but we should commend the Government on the detect cancer early programme and welcome the partnership between the Teenage Cancer Trust and that programme. There is much to celebrate. Today, in particular, we celebrate the work of the Teenage Cancer Trust. I am sure that we would all like to unite in thanking it for all that it has done and will do. Finally, we should once again pay tribute to Aileen McLeod.
17:38
I congratulate my friend and colleague Aileen McLeod on bringing this debate to the chamber. Aileen’s personal testimony serves to remind us that many members have experience of issues beyond our comprehension. It took a great deal of courage for Aileen to relate her personal experiences in Parliament and I thank her very much for doing that. I could not begin to imagine the circumstances undergone by somebody who was diagnosed with cancer at such an early age. It is a great credit to her that she is using the opportunity that she has as a member of the Parliament to raise awareness and to bring this debate to the chamber.
I also thank the Teenage Cancer Trust for its briefing in advance of this debate and I thank Amy Quinn for her letter. It cannot have been easy for her to relive the experience and write it out for members of this Parliament to read. I read it and I was struck by its content.
Although detecting cancer as early as possible is obviously a healthcare issue, I have identified an attitudinal issue in the briefing and in Amy’s letter. We need to look at how seriously we take young people when they present with health problems and ensure that they are not dismissed as readily as Amy’s fears about her health were. All too often in society, we do not listen enough to young people when they talk about their problems. We need to do that.
When it comes to the wider attitudinal agenda, I absolutely agree that we need to raise awareness of the issue. I note from the briefing that
“Cancer is the most common cause of non-accidental death in young people, and five-year survival rates remain lower in teenagers than in children. While cancer in this age group is rare, it’s vital for young people to know the common signs so they can seek medical advice if they are worried.”
It is not just a case of educating young people by talking to them; it is also about getting young people to be more open to talking about the issue among themselves. It strikes me that there is a parallel with the conversations that we have had about mental health, in that it is not a comfortable subject for people to talk about; it is not the sort of thing that they talk about at the dinner table or among their peers and friends. If we make people comfortable enough to open up about it, to discuss it and to help one another through difficulties by spotting the signs, we can save lives.
The work that the trust is doing, which I read about in its briefing, is fantastic. We should look at how we can replicate that work across Scotland. I am aware from conversations that my office had with the trust that it has not yet expanded its services into the Aberdeen area. I look forward to having a discussion with the trust about whether it has plans to do so in future, and about what MSPs who represent communities where it does not yet have a reach can do to take its message to health boards and health professionals. I would be happy to have such a discussion, perhaps at the reception, if I am able to attend it.
I commend Aileen McLeod for bringing the issue to the chamber. If, as a society, we can become more open in discussing issues to do with cancer—particularly as it affects young people—I think that that will go some way to resolving some of the issues that the trust has identified.
17:42
Over the past 10 years, I have participated in many members’ business debates on health-related topics that have highlighted excellent work in Scotland that is not widely known, but which should be. The Teenage Cancer Trust’s education programme falls into that category, and I would like to thank Aileen McLeod for bringing it to our attention this evening.
We are all familiar with the high incidence of cancer in the general population, but I admit that I was surprised to learn that, across the UK, as many as seven people between the ages of 13 and 24 are diagnosed with cancer every day, which equates to an average of 203 teenagers and young adults being diagnosed in Scotland every year. Yet, when I stop to think about it, I know or have known several people in their teens and early 20s who have developed leukaemia, sarcoma, melanoma, liver cancer or some other malignancy.
However, cancer is not a condition that we generally associate with young people, so as well as it being particularly frightening for someone in their teens to be faced with such a diagnosis, the symptoms are not always recognised for what they are, even by the medical profession, as we have heard. The result is that diagnosis is often delayed, which, of course, is not good for the patient, physically, psychologically or emotionally.
The work of the Teenage Cancer Trust in educating young people about the symptoms and signs that might indicate the presence of cancer is extremely important, as it gives them the knowledge that will help to empower them to take responsibility for their health, and to dispel some of the fears and misconceptions that they might have around cancer.
The signs of cancer in young people can easily be missed, because they often resemble those of other, less harmful conditions, but it is alarming that the trust’s research has found that as many as 40 per cent of young Scots with cancer see their GP four times or more before their symptoms are taken seriously or they are referred to a specialist. Amy Quinn’s experience, which was so clearly expressed to us ahead of the debate, illustrates that graphically. Young people need to be educated about the signs of cancer, and they certainly should not have to worry about talking to their GP.
The Teenage Cancer Trust’s education programme gives free information, education and advice about cancer and its prevention, and about healthy living, to around 130,000 students and teachers across the UK every year and, last year, it visited 95 schools in Scotland, through which it reached more than 11,000 students. As a result, increasing numbers of young people are looking to take control of their own health and are feeling able to speak up if they are worried about some physical change and to discuss cancer openly with others such as family and friends.
In preparing for the debate, I came across some very appreciative words about the education programme from pupils and teachers who had found it very informative and felt that it was presented in an interesting and thought-provoking way and pitched at the right level of giving information without being overly dramatic. In one very moving testimonial, a young boy who had attended an education event felt able to tell his mum about a testicular lump that had been worrying him for two years. Fortunately, the lump turned out not to be cancerous, but the knowledge that he gained gave him the courage to discuss his problem, which, of course, could have been much more serious.
The recently launched partnership between the Teenage Cancer Trust and the Scottish Government’s detect cancer early initiative is exciting and I hope that, if it proves to be successful in Glasgow schools over the next year or so, it will be rolled out to other parts of Scotland including, as Mark McDonald has suggested, my area, Aberdeen.
We need to publicise the Teenage Cancer Trust’s work, not least the specialist teenage units that it has provided in NHS hospitals right across the UK, including the Beatson centre in Glasgow. Of course, the debate is specifically about the trust’s education programme, which I am very happy to endorse, and I once again commend Aileen McLeod for bringing the issue to our notice this evening and for sponsoring the trust’s parliamentary event on 6 November, which I look forward to attending.
17:46
I, too, congratulate Aileen McLeod on securing the debate, and acknowledge the good work that she has done on the matter outwith Parliament. As Mark McDonald made clear, Parliament is all the better for people bringing their personal experiences to it.
The debate is also timely, coming as it does just before teenage cancer action week, and it provides members with the opportunity to pay tribute to the outstanding contribution that the Teenage Cancer Trust has made for more than two decades in the UK.
Teenagers tend to think that they are invincible and impervious to disease—especially to serious illnesses such as cancer. Indeed, the perception is that cancer is reserved for those in later life. There is also an element of unintentional ignorance. A Teenage Cancer Trust survey revealed that more than half of 13 to 24-year-olds believe that we are all born with the cancer gene and that just over a fifth believe that the colour of one’s skin determines whether one gets cancer or not. The natural naivety of youth is to be expected, and teenagers can be forgiven for not immediately associating fatigue, swelling and pain with cancer. That is why the trust’s free education programme is so vital and must be commended.
That the trust’s advocates and educators reached more than 11,000 students in Scotland during the 2011-12 academic year is an achievement to be proud of but, given the personal testimonies of teenage cancer sufferers and the trust’s statistics, it seems that educating teenagers on cancer’s warning signs is only part of the battle.
Too many of our young people are having to make multiple presentations to healthcare professionals before a diagnosis is finally made. It should worry all of us that two thirds of the young cancer sufferers who were surveyed believe that their diagnoses could have been made quicker, and that 40 per cent of young Scots with cancer said that they had to visit their GP at least four times before they were referred to a specialist. That statistic is very troubling—particularly when one considers that the subsequent target for treating those youths would be to do so within 62 days. That is a considerable length of time for people who have had symptoms for a while.
Early diagnosis and treatment for cancer patients of all ages are vital, and although improvements have been made there are still areas of Scotland where not enough patients are being treated within 62 days of a referral for suspected cancer. For instance, the target is 95 per cent, but for NHS Grampian the figure is 88.9 per cent and for NHS Borders 91.8 per cent. The situation is worse for specific cancers, with the national average for cervical and urological cancer standing at 88.6 and 88.2 per cent. If those are the averages, some boards will—naturally—be performing worse than that, and perhaps significantly so.
Education programmes are important, but so is ensuring that the infrastructure and personnel are in place to deal with patients when they receive the dreadful news. I commend the people at the Teenage Cancer Trust, who do important work, and those in the NHS who continue to treat and look after cancer sufferers. I congratulate Aileen McLeod again on bringing the subject to the chamber.
17:50
I join colleagues in thanking Aileen McLeod for lodging the motion and I join her in thanking the Teenage Cancer Trust and all its supporters for the fantastic work that they do to support young people across Scotland. Cancer is a terrible disease at any age, but it can be particularly devastating when it affects the young.
Prevention needs to remain a priority, but we also know that the earlier we diagnose cancer, the more likely intervention is to succeed. I have no doubt that the trust’s education programme could make a substantive difference in raising awareness among 13 to 24-year-olds and in improving detection.
It is essential to highlight this evening and during October’s teenage cancer action week the need to support our young people who are diagnosed with cancer during their school and college years. According to research by CLIC Sargent, two thirds of 16 to 18-year-olds with cancer said that they fell behind in their studies or performed worse than expected. Three out of 10 said that they had to leave education altogether. When CLIC Sargent asked teachers for their views, only 15 per cent of secondary teachers said that they had enough information or guidance to support a pupil with cancer.
Children and young people face many challenges and obstacles in continuing their studies while coping with or recovering from cancer, such as fatigue, problems with concentration and emotional difficulties. Even changes such as weight gain that is caused by medication can add to feelings of isolation and self-consciousness, to which Aileen McLeod eloquently and tellingly referred.
I thank the Minister for Youth Employment for her answers to a series of written questions that I have submitted on the issue, but there is more that she and her colleague Mr Matheson, the Minister for Public Health, could do. That includes a formal needs assessment when young people return to school, one-to-one tuition to fill any gaps in learning and good practice that ranges from reorganising timetables to a personal expression of interest from the headteacher.
One of the most interesting and important developments in England and Wales has been the introduction earlier this year of new guidance for local authorities that sets out their legal responsibility to ensure that children and young people with medical needs receive a good education. I understand that that might have been accompanied by a new system of funding for hospital education. I am sure that the minister is aware of how varied the hospital education picture is in Scotland. I would welcome his comments on whether the Children and Young People (Scotland) Bill is the right vehicle to address that troubling issue.
I commend the work of the Teenage Cancer Trust and the motion from Aileen McLeod.
17:53
Like others, I congratulate Aileen McLeod on securing time for the debate and bringing to the Parliament’s attention the important work that the Teenage Cancer Trust undertakes daily. I thank the trust for the tremendous amount of work that it does over the year and particularly for its close working with our detect cancer early team, to which some members have referred.
I recognise that the fear of being diagnosed with cancer is still one of the biggest imaginable, particularly for children and young people. A diagnosis of cancer often proves traumatic not only for the affected individual but for their family.
Thankfully, the number of children and young people in Scotland who are diagnosed with cancer every year is relatively small. However, when they are diagnosed, that can have a significant impact on their life, particularly as they might be at a stage when they are finding themselves and at a key point in their education—that can have a lasting impact. It is therefore important that all our services are able to work collectively in order not only to treat an individual as effectively as they can clinically, but to look at the holistic picture around how they can provide them with support and assistance in education and in other areas.
It may be helpful if I set out for members how we provide children and young people’s cancer services in Scotland. They are largely taken forward through our managed service network, which Malcolm Chisholm referred to.
The managed service network was established in 2011 and it is there to help to ensure that we have sustainable services across Scotland for young people up to the age of 15. I note Malcolm Chisholm’s concerns about the fact that some of the areas of progress that were set out in the action plan have not been achieved as yet. However, the action plan does run up until 2015 and there is an annual report that sets out the progress that has been made and also identifies what future action has to be taken in order to ensure that we maintain progress in this area. I hope that Malcolm Chisholm will be reassured that there is certainly more that we can do in this area and the managed service network is determined to do so.
It is also worth noting that the managed service network works closely with the professionals who work in this field and with third sector colleagues, and has had very helpful contributions from organisations such as the Teenage Cancer Trust. Most important, it also has input from children and young people and their families.
I recognise that the members of the managed service network have taken forward an outstanding level of work to date and they are starting to make a change in how services are delivered. I have no doubt that they will wish to continue with that work between now and 2015.
We have heard about the numbers of young people who can be diagnosed with cancer—about 170 teenagers and young adults aged between 15 and 24 are diagnosed with cancer each year in Scotland. Very often, the signs of cancer in young people—as some members have mentioned—can easily be dismissed. They can also be misdiagnosed, because they are very similar to signs of other issues that may be less harmful and are confused with those issues.
Amy Quinn set out powerfully in her letter the challenges that some young people can face in being able to get their condition appropriately diagnosed and then treated. That demonstrates the need for further work in this area, in particular with our colleagues in primary care—who may be that first port of call—to enable them to recognise the issue more quickly. Part of the issue is to do with the cultural aspect that cancer is often associated with older individuals and not often with young people. However, the earlier a diagnosis is undertaken, the better. That is why I believe that GPs have an important part to play and part of the work that we need to do is about how to improve understanding and communication within a primary care setting—in particular with our general practitioners.
Of course, I recognise that everyone would be naturally apprehensive about being checked for cancer but, as we recognise, early detection of cancer improves the chances of a positive outcome for treatment. Cancer remains a clear priority for us as a Government, as we acknowledge that we are behind other parts of Europe on cancer survival rates and, with an ageing population, we can all anticipate that there will be an increasing incidence of cancer in future years. The detect cancer early programme is important in helping to improve outcomes for patients.
That leads me on to the education programme that the Teenage Cancer Trust has been involved in. If we educate young people at an early stage about their health, the risks of certain conditions, symptoms and so on—as several members have mentioned—that education can live with them for the rest of their lives and it can help to ensure that they take appropriate action at an early stage should they exhibit any of those symptoms. Equally, young people who have been through such an education programme can assist in giving a gentle nudge to a family member who may be exhibiting symptoms of cancer to take medical advice at an early enough stage.
The Teenage Cancer Trust’s work in helping to educate young people in our schools—Aileen McLeod referred to a programme the trust is running in Glasgow—can help to make a real difference to the understanding of those young individuals about both the potential symptoms of cancer and the lifestyle risk factors that can contribute to cancer, which may be extremely important for them in later life, if not when they are teenagers. We will watch with real interest to see how that programme develops. Such work can also complement our detect cancer early programme, which works with adults, by encouraging the young people, as I said, to give that gentle nudge to a parent or family member to take early action if they seem to be exhibiting symptoms.
I am conscious that Ken Macintosh raised an issue about the Children and Young People (Scotland) Bill. I will ask my colleague who is leading on that bill whether measures could be taken to assist in strengthening hospital education provision in order to achieve greater consistency.
In drawing my remarks to a close, I offer my sincere thanks for the tremendous work that is done by the Teenage Cancer Trust. In particular, I thank Amy Callaghan for attending the debate along with her colleagues from the Teenage Cancer Trust. I also thank Amy Quinn for the moving letter that she wrote to all MSPs, in which she set out issues that still need to be addressed to improve the way in which we support young people who may have cancer.
Meeting closed at 18:01.