Hello and welcome to this Skin Deep podcast where we look at skin-related issues, conditions and treatments in an interesting and informed way. I'm Dr Roger Henderson. I'm a GP with a long-standing interest in this area of health. And I'm Dr George Moncrieff. I was also a GP, although I've now retired from my practice, and I was the Chair of the Dermatology Council for England. Now today, George and I are going to be discussing malignant melanomas.
And we're going to look at their cause, some figures as to how common they are now compared to some years ago, and whether we're actually approaching them the right way. Now, I know you've got some pretty strong views here on this topic, George, so I think this is going to be an absolute cracker of a podcast. But let me start by asking, a perhaps an obvious question, as to why spotting a malignant melanoma by doctors has rather become like the shark in Jaws.
Everyone's afraid of it, everyone's talking about it, and everyone's keeping a constant lookout for it. Indeed, they are. Yeah, it certainly punches well above its weight, I think. That's not to say melanoma isn't a terrible diagnosis. I think part of the problem is that doctors recognise that they're not forgiven, if they miss a melanoma. And that's borne out by the fact that we're ten times more likely to be sued for missing a melanoma than missing any other cancer.
Society, the courts, journalists, everyone is ruthless if a doctor misses it. They expect us to get this one right. So, that's the first point. The second concern is that they are getting more common and it's increasing in incidence faster than any other cancer I know. So the incidence of melanoma is doubling every 10 years and has done so now for the past 40 or 50 years. If you look back at 1998, the figures were just five cases of melanoma per 100,000. That's now over 20 per 100,000.
So it's increasing quite fast. Admittedly, I think some of that increase could be down to changes in the way in which we make a diagnosis of melanoma. In the past, I think people looked under a microscope and dismissed something, whereas now, with special immunochemistry testing and other things that histopathologists can do, they can recognise that something is a melanoma.
So it's labelled a melanoma, where in the past it might have been called a dysplastic naevus, which just means a mole that's not looking very healthy. The vast majority though, of this increase of melanomas, are what we call melanoma in situ. Now, dermatologists agree with me that a melanoma in situ is almost a benign lesion. We, think that left to their own devices, they will become invasive melanomas.
But there's definitely a body of opinion developing, that there are very early melanomas, which are very flat, which are almost benign, and that the patient might die with them and not from them. And all this increase that we've seen over the last 40 years has been predominantly of these very early, in situ, almost, benign is almost the wrong word to use, but very low risk melanomas. And so, I used to say, don't call them malignant melanomas, because they're all malignant.
But I've now gone back to calling them malignant melanomas. And in my mind, I'm also thinking quietly, that there could be more benign melanomas, these very flat, whirly ones, which, I'm just a bit worried I might have imposed a diagnosis of melanoma on some of my patients, when in fact they had a lesion that was never going to cause them any harm at all. Unfortunately, we will never know the answer to this, because no one's going to be brave enough to leave them.
I've certainly seen early melanomas that the patient says, this one hasn't been changing for at least four or five, six years and I look at it and I say, well, it's clearly a melanoma and it is, when it's excised, and you just wonder. But the current lifetime risk of somebody getting a melanoma is about one in 36, in men, a bit less common in women, almost one in 47 women, so almost 3% in men and almost 2% in women.
Okay. And I'm with you, you know, you've got to be very careful about malignant melanomas and benign melanomas, but I tend to reserve malignant melanomas for when we know they are. So it's obviously increasing, quite fast. But what about the ages of people that we see it in? My back of an envelope calculation compared to say 20, 25 years ago, is I'm probably seeing fractionally more younger people with it, but the bulk still remains the older population. Yeah, it's exactly that.
Yes, it gets common, more common, as you get older. And its peak age of incidence is in the 85 to 89 year olds. And I suspect it would continue to increase per capita beyond that, but just there are less people alive after the age of 90. So the peak age for seeing a melanoma is in the 85 to 89 year old group. But as you say, it's also a cancer of young people, and it's increasing fastest in individuals under 55. That's the cohort in which the incidence is increasing fastest currently.
But about 4% of all melanomas occur in very young adults, 15 to 34 year olds. Devastating stage in your life to be given a diagnosis of a melanoma. And so, it's not an uncommon condition but it causes this huge anxiety that we talked about earlier. And as a consequence, half of all referrals by a GP to the cancer bureau, the two-week wait bureaus, are referrals of a lesion on the skin. And I think this is the real problem.
We are overloading secondary care with these huge numbers of patients that we are concerned about because of what their lesions are looking like. Half of all referrals to dermatology are for suspected skin cancer. But this is a very interesting point. Only 6% of our referrals to the skin cancer two-week bureau turn out to be either a melanoma or the other cancer that matters, which is a squamous cell carcinoma. 94% are benign, nothing to worry about.
So the purpose of that two-week bureau is to manage these potentially nasty cancers rapidly, but only 6% turn out to be anything to worry about.
And more worrying to me than that, is some figures that I got from the president of the British Association of Dermatologists, when I was working at the Dermatology Council for England, and he said he'd done a Freedom of Information Act report through all the trusts in the country, asking the dermatologists he knew, how many of the referrals from GPs that we had referred as suspected melanoma, or other cancers, were obviously benign?
They could take one look at this and they say nothing to worry about. And the figure that came back was 84%, are not just benign, but in their view, were obviously benign. So there's a big issue about what GPs are sending to secondary care and overloading secondary care. And I think that we'll come on to that in our next podcast when I'll be talking about that in more detail. I think so.
If we've got such a huge number of benign or harmless skin lesions, I'm struggling to think about any other cancer, potential cancer diagnosis, referred into a two-week pathway, when you've got such a low pickup at the end of it. But we're obviously speaking in times of massive waiting lists. And we're obviously going to be further overloading it, compromising the ability of dermatologists to provide a service.
But I know of many anecdotes where colleagues have been, almost pressured, into referring, by patients who've looked at Dr Google or whatever, even then, when they were 99% certain their skin lesion was benign, and this is the key point. But I guess we come back to that, what we talked about right at the top of the podcast, the fear of both missing a skin cancer or, in my view, probably more of an issue, being sued if we do. We're almost sued if we do and sometimes sued if we don't.
And I think this is where you've got pretty strong views, on the advice that as GPs, we are being given advice from the top, if you like, on this. I do indeed. Yes, that is a, clearly, a major issue. And of course, as GPs, we, well certainly in my day, we lived in the community. The cinema I went to, I sat next to my patients, the supermarkets, I was in the queue behind my patients. My wife taught my patients at the local school.
So you live in that community and when you make a mistake, it's obviously a disaster for the patient, but that word gets around, and it's not just being sued. You are, where you live, your home, whole life is surrounded by your mistakes. Agreed. So you can't afford to get it wrong. And so clearly, you know, doctors are going to err on the side of being cautious, not just for their patients, but also selfishly for themselves.
But I believe our whole approach to diagnosing melanoma is, I'd actually say, dangerously flawed. And I'll come on to that in a lot more detail next time, where I'll be discussing NICE's and the British Association of Dermatologists', frankly, infatuation with what's called the ABCDE approach to recognising a melanoma.
I think using that approach is responsible for a lot of the problems that we're having in primary care with distinguishing these obviously benign lesions from the potentially more serious melanomas and things. ABCDE causes huge anxiety with false positives, i.e. referring what turn out to be obviously benign lesions that fail that system for looking at lesions.
And it even accounts for some of the false negatives, i.e. the patient has got a melanoma, but it doesn't reach the criteria for ABCDE to make you concerned. So it fails both ways. I think medicine is far more sophisticated than just reciting the alphabet, and I think that we need to be much more intelligent in our way of looking at melanoma in the community and recognising which patients we need to be worried about.
Yes, I think I agree with that, and the medical students that I teach, you know, do have ABCD sort of, imprinted on their foreheads. And I suspect there are quite a few people listening, wondering what the George approach to melanomas is instead. Now, my best guess with you is that you start with the general perceptions around melanomas and then work up from there, to look at the actual risk factors across the whole area, and I'm thinking not just the impact of ultraviolet light.
So that's where I'd be coming from. Do I win a goldfish? I think you win a cluster of goldfish actually. Yes. You've got it in one I think. Yeah. Well, I think my approach starts off with, is this patient, who's worried about something, or the patients I've seen a lesion on, are they a candidate for a melanoma? Are they somebody who is likely to get a melanoma?
And when I talk to colleagues about this, or even the public, more, I think when I say to them, you know, "what are the risks of getting a melanoma?" They say, "well, it's sunlight. Full stop. It's going out in the sun, and however much you get exposed to the sun, that's what causes your melanoma", and that's as far as they think. But in fact, let's look at the actual risk factors. Well, the first thing I think, to say is that age matters.
I've already mentioned that melanoma, is more common in the very elderly, but turn it the other way around. Children and young adolescents, people under say, 14, 15, certainly risk under the age of 11, is virtually nil. There was a study from Bristol a couple of years ago. They looked at all the referrals to their two-week bureau of children, under 11. There were 79 referrals over a two year period. Doctors had referred the patients, these children, concerned that the lesion could be melanoma.
They didn't have one melanoma in their study, at all. So children under 11, almost however ugly the lesion looks, you can be very relaxed. It doesn't mean I wouldn't ask a specialist to give a second opinion, but I'm very relaxed indeed about children under the age of 11. They don't really get melanomas. Apart from perhaps the one exception, well two exceptions, one is the quite rare thing called a spitzoid melanoma, which looks different and I won't go into that here.
That's not, it's not that uncommon in children, but they don't tend to have a terrible prognosis and under 11, they're usually not too serious anyway. And the other is the child who's born with what's called a bathing trunk naevus, where, for example, the half of their body has a huge pigmented patch, often hairy, covering the whole of their buttocks and half their tummy and things. Within that, there's a tiny risk of getting a melanoma. So first of all, children, don't worry.
The things that alert me and make me instantly much more concerned is a patient who's had a previous melanoma. If somebody's had a melanoma before and they've now got a lesion that they're concerned about, or is changing in some way, I'm anxious. Somebody who's had one melanoma has a 10% risk of having another. So they need to be watched, carefully.
Similarly, if they've got a first degree relative, a brother, sister, parent, who's had a melanoma in the past, well, that doubles that individual's risk of a melanoma as well. So, those are two really important risk factors. The next group of patients I'm concerned about are the patients with multiple moles. We all see these patients from time to time. They've got loads of moles.
And I'm not talking about, what we call these benign pigmented things on the skin, which often most of us get when we get older, sun spots and seborrhoeic keratoses, these rather greasy, warty, crusty, sharply demarcated lumps usually on our trunk. But if you've got moles, actual moles, which doctors call melanocytic, because they've got cells that produce melanin, melanocytes, naevi, that themselves, they're benign moles.
But if you've got more than 40, which is not uncommon, that doubles your risk. You've got the genetic makeup for melanoma. If you've got over a hundred moles, you've got seven times that risk, the normal risk. And if five of them are looking a bit odd, irregular, in themselves they're perfectly fine, we call those atypical moles. But if you've got more than five atypical looking moles, then you've got six times the risk.
So, patients with multiple moles, I'm concerned about, and I'm concerned about them for two reasons. One, they're more likely to get a melanoma, and two, when they get a melanoma, it's a devil's own job to spot it, because initially, when it's small, it looks just like their other moles. And the only way in which you can really reliably say this is a melanoma and not just one of the moles you've had for years is having serial photographs.
You've got a photograph of what your back looked like last year and now there's a mole there that wasn't there, then that's the one to worry about. While I'm on the subject of moles, by the way, most of our mole population appears from about the age of 11 or so, 8, 9, 10, 11 onwards, and we develop most of our moles in our early adult years, up to in our teens and early 20s.
I don't like new moles appearing after the age of 30, and I get particularly anxious about anyone having a new mole over the age of 50. But the risk of these acquired moles becoming a melanoma is trivial. It's about, if you've got a mole, the risk of that mole becoming a melanoma is about 1 in 200,000. Wow. And to be honest, that's no different really, from the neighbouring normal skin. So cutting out a mole to prevent it one day becoming a melanoma, you might as well just take all the skin off.
It's pointless. Slightly different with congenital naevi. If you've got a congenital naevus, i.e. that's a naevus that's been there from birth, the risk of those one day turning into a melanoma is very small. It's about 1 in 200, and that's likely to happen in later adult life.
In fact, the overall risk of a congenital naevus one day becoming a melanoma is more like 0.8% which is fractionally more, but that includes the rare but very large so called giant congenital naevi which can cover the whole buttocks and are really huge.
But those are closely followed up in hospital, those are uncommon, but the risk of melanoma within those is significantly more and so that raises the overall risk of a congenital naevus one day becoming a melanoma, but when you discount those, the actual risk of a small to medium sized mini naevus that's been there from birth or a few months after birth is only 1 in 200. Most of those don't do anything. They either disappear or they turn into what's called intradermal naevi.
But there's a small risk. So those are the major risk factors. Past history, family history, multiple moles. Today's podcast has once again been made possible by the kind support of AproDerm®. AproDerm® is the company behind a range of innovative emollients that include creams, a gel and an ointment, all formulated to soothe, moisturise and protect the skin affected by a whole range of dry skin conditions, including eczema, psoriasis and ichthyosis.
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I encourage you to try AproDerm® and see the results for yourself. Thanks again to AproDerm® for sponsoring this groundbreaking podcast and helping us provide you with the best care possible. Obviously, skin type matters, and I'll be discussing that in a bit more detail. But if you've got ginger hair or, that alone, just having ginger hair, doubles your lifetime risk of a melanoma. In fact, more than doubles it. It's between 1.5 and 3.6 times increased risk. So, that's certainly a risk factor.
Turn it the other way around, having very dark skin, Caribbean sort of skin, really, sort of, dark brown, the risk of a melanoma on the skin, what we call a cutaneous melanoma, is vanishingly small. Melanomas on the foot, on the fingerprint skin, so the soles and the palms, and around the nails, at the same rate with white skin. Mucosal cancers, melanomas, I mean, so you can get it in the nasopharynx, that's behind the nose, or inside the nose, in the nostrils, or in the throat.
I've even seen a melanoma in the stomach. So you can get melanomas elsewhere, and they're just as uncommon in dark skin as they are in light skin. But all these things, ginger hair, skin type, genetic factors, I'm sorry multiple moles, family history, so these are all genetics, and you can't change any of those. That's your genetic makeup that gives you a predetermined risk of developing a melanoma, one day.
Yeah, and I said, listening to that made me come back to the point we've often mentioned in our podcast, which is, take the history, even before you sort of put your eyes on someone's skin, actually take the history, because the patient is likely to tell you an awful lot of what you're going to need. So, you know, you ask about the family history, you ask about whether they've had skin problems in the past and that sets you on the road.
Now ultraviolet light, as you mentioned earlier, you know, everyone thinks about ultraviolet light. The other thing we, but before we even talk about that, the other thing that I sometimes have to remind myself to, to remember, if I'm thinking about someone with melanomas, is immune suppression in patients, the impact of immune suppression, and again, taking the history.
Is there anything which is going to impact on the immune system, which in turn is going to fire up the possibility of melanomas occuring. Yep, that's such an important point. Yep, it's estimated that in our adult life, each of us is producing one new melanoma cell every day. But our immune system is spotting that quickly and removing it. So it's not a problem.
But if you suppress that immune response for whatever reason, if you're on long term steroids, perhaps for asthma or another medical condition, or if you're on drugs that knock your immune system because your immune system is messing up, azathioprine is an example, then your body's ability to clear that melanoma cell early is diminished. Patients with HIV or lymphomas and things like that, they are, their immune system is dysfunctional.
And the organ transplant population are looked at very carefully. They have two and a half times increased risk of getting a melanoma. They have a much more increased risk of getting other cancers of the skin, squamous cell carcinoma.
So, my patients who've had organ transplantation, where their immune system has to be calmed down fairly aggressively, to prevent them rejecting their transplant, they're usually under secondary care in hospital, having their skin checked, at least annually, and they're given a lot of advice on reducing modifiable risk factors like ultraviolet light.
So yeah, I think immune suppression is very important and I do feel that as GPs, if you've got somebody whose immune system is not working as well as it should be, for whatever reason, they're very old, that's perhaps why melanoma gets more common as we get older, our immune system becomes less aggressive.
Or they're on drugs that knock it, or they've got another condition that affects their immune system, then they should be given good advice about sun protection and probably, in my patients certainly, I would check their skin annually. Yeah, you mentioned ultraviolet light there. So let's look at that now.
I think you and I definitely agree about risks of sunbed use and especially now, in teens and young people who are image obsessed and again, without wanting to hark back to the old days before social media, again, in my practice, undoubtedly, one of the huge changes I've seen is the impact of social media on some health behaviour in younger people. And I think ultraviolet light, sunbed use, tanning, is perhaps the biggest example I can think of that's changed in the last 20 years.
And I did some work on this recently, and I came across a statistic that actually made my jaw drop so much, I didn't believe it, and I went away and checked it again before I actually believed it and realised that the statistics were sound. And that statistic was that there were more skin cancer cases caused as a direct result of sunbed usage than of lung cancer cases caused by smoking.
I still can't quite believe I'm saying that, but it appears to be generally the case and sunburn, and obviously, as we all know, the sign of a so called healthy tan is actually a sign of significant skin damage. Sunburn, and the use of of sunbeds, is a real power up here when we're specifically talking about ultraviolet light, aren't they? Well, it's very complicated, but I think that's a staggering statistic, isn't it? And I'm not surprised, but it is pretty amazing, isn't it?
Yeah, I'm proud to say that I was a, sort of, low grade member of, I wasn't a proper full member, of the All-Party Parliamentary Group for Skin Disease, but I attended their meetings about six, seven years ago, when the APPGS managed to get a law passed making it illegal for anybody under the age of 18 to go and use the sunbed. So I think, in the UK, so I think that was a very important thing to do. Yeah, ultraviolet light, it is terribly important because it is the one modifiable risk factor.
You can't really do much about the immune suppression, which is usually important. You can't do much about your genetics. And a history of sunburn. It seems to be episodes of, intermittent episodes of, intense sunlight, ultraviolet light, that causes the risk for melanoma, whereas it's the low grade background, cumulative sun exposure that causes the keratotic cancers, things like squamous cell carcinoma, which are usually much lower grade, much less worrying, but they're still cancers.
So it's low grade background sunlight, just has a cumulative risk increasing for the non melanoma skin cancers. Whereas melanoma seems to be something to do with episodes of intense burning sunlight. So, children under 11 their melanocytes, which are the cells that produce melanin, are migrating to the skin, and they migrate from the spinal cord area, and they take about 10 years to get there, which is why our mole population appears in our adolescence.
That's when the moles are getting there, they're arriving in the skin. But the ability of the skin to protect itself is therefore compromised, and so children under 11 are particularly vulnerable to ultraviolet light, and I think they should be kept out of the sun as much as possible, and given vitamin D. They should be covered up, use quality sunblock, and kept out of any worrying intense sunlight. One episode of severe sunburn doubles your lifetime risk of melanoma.
And using a sunbed ever, just using it once, increases your risk by 20%. Wow. And if you do that in young people, in people under 35, that risk is actually increased by 59%. So, these are huge increased risks so, and actually sunbeds also increase the risk of these other cancers, like squamous cell carcinoma, it increases the risk even more by two thirds, to 67%.
So, sunbeds, from my point of view, are definitely a no, and I will come onto those in more detail later, but essentially they are, it's hard to regulate the amount of ultraviolet light they're producing. They're producing a lot of UVA, and although UVA doesn't burn, UVA wave ultraviolet light penetrates quite deep and increases the risk quite considerably.
I think the, taking all that apart though, avoid sunbeds, avoid intense sunburn or intense ultraviolet light, episodes of sunburning, enough to cause your skin to peel or blister. Those are a disaster. Apart from that though, I have to say, I am on my own in this, and this is not the view of dermatologists, but I think that non burning, sensible, ultraviolet light exposure, in adulthood, is not a huge risk factor for melanoma. Yes, it's the one thing we can modify.
But it's not the major risk factor. The major ones are the ones I've talked about. Family history, past history, multiple moles, immune suppression. So it's a complicated message, but... when you make a tan, these melanocytes produce little packets of melanin, called melanosomes, and those are taken up by all the cells in the epidermis, the top layer of the skin, and then that melanin is released as globules in the cytoplasm of those cells. Now this is the clever thing.
What then happens is that they aggregate on the outer surface of the nucleus of the cell, like an umbrella, protecting the nucleus from the ultraviolet light getting through, so that the DNA of that cell is not damaged. But they leave the cytoplasm clear, so that's where you produce the vitamin D and the other things that sunlight does which are good for you.
So, I argue that if you've got, if you've built up a gentle tan, and I don't mean a tan that ends up with lots of freckles and sun damaged spots, age spots, sun spots, solar lentigos, whatever you want to call them, but you've developed a nice even tan, what you've managed to do is you've managed to put an umbrella on the outer surface of all the nuclei of your epidermis, and are protecting your epidermal cells from ultraviolet light, and you're then getting all the benefits of sunlight as well.
Now that's a highly controversial view, but I think in adulthood, carefully and sensibly building up a tan over a period of time, might be a very reasonable thing to be doing. I will come back to that. But yeah, I accept, most melanomas do occur on sun exposed skin. Interestingly, it's on the back in men and on the legs in women. Maybe the thought there is that in women, it's because they often wear a skirt and the light is reflecting off the ground and hitting their legs.
But one thing we do know that is if all people with white skin, used total sunblock, 24/7, we would only stop about a third of melanomas. Two thirds of melanoma would still occur. So yeah, sunlight, unquestionably matters. And yes, sunlight is something we can do something about. And yes, getting an invasive melanoma is horrible, but it's, it's not the whole story.
And to put that into context, there was a recent study in the Journal of the American Academy of Medicine and they compared Puget Sound in Washington with Orange County in California. Two populations that have completely different ultraviolet light exposure. And they matched these two populations for all the possible variables that they could come up with, and they looked at the number of melanomas occurring in those two populations. They were almost identical.
72 cases per hundred thousand in Puget Sound in Washington state, and 73 cases in California, a state where they're gonna be even more alert to the risk and the possibility of getting a melanoma, and so more likely to go to their doctor. And the conclusion they came to is that we do need to consider whether the time has come to be a little bit more circumspect about our messaging over ultraviolet light. I think there's almost too much anxiety generated by stressing ultraviolet light, in adults.
I think in children, ultraviolet light protection is important. What I say is, I think children should be kept in the dark. Perhaps in more ways than one. But I think in adults, I think we simply need to avoid sunbeds. Avoid severe sunburn, and I think, use sunblock sensibly to enable us to build up a sensible tan, and that's what I do.
When you talk to Australian dermatologists, they'll often talk about the Australian truckers' arm melanoma, and this is a good example of the high intensity, blistering and burning, because Australian truck drivers driving along in the heat, they will stick their left arm on, out of the window as they're driving along, and nine times out of ten, that's where they power up their melanoma, if they're going to get one, and that actually chimes exactly with what you're saying.
There's nothing about gradual low level acclimatisation to sensible levels of UV light. This is just constant day in, day out, that arm is being hammered by high intensity ultraviolet light and that's what tends to power them up. Just a final point, George, am I right in thinking that low altitude populations, compared to populations living at higher altitudes, are at a higher risk of melanoma? I seem to remember reading that somewhere. Yep, you're absolutely right.
It's very interesting, isn't it? UVA, which doesn't burn, goes straight through glass, straight through cloud, and it penetrates our atmosphere very well. So, at low altitude, you're getting quite a lot of UVA. UVB doesn't go through glass, it doesn't go through cloud. UVB is a hundred times more burning than UVA. So, we know you don't burn, for example, indoors, you don't burn on a cloudy day.
And at the extremes of the day, when the sun's low and you've got to go through more atmosphere, UVB is also filtered out. So you don't get UVB at all. But UVA does penetrate down into very low altitudes. And so populations at these low altitudes, they're not going to burn. They're not going to tan very well either. UVA doesn't produce much tanning. It causes release of those packets of melanin I've talked about, but it doesn't stimulate the production of more packets of melanin.
So you don't get a good, permanent tan from UVA. So, interestingly, yes, UVA is penetrating the atmosphere, it's penetrating their skin deeper, and it does seem to be associated with a higher risk of melanoma. And that might go some way to explaining the worry with sunbeds, because sunbeds have this high intensity UVA. Yes, exactly. And it's, maybe that is what's the risk, along with the intermittent episodes of intense UVB burning with blistering and peeling.
But it's a complicated story, isn't it? It is, it really is. But I hope that for everyone listening, that they found this complicated story interesting, helpful, and allowing you to have more confidence in understanding a little bit more about melanomas and the risks involved with them across the board. Roger and I hope you'll join us again next time, where we'll be discussing some of the potentially tricky areas about how to diagnose a melanoma. Some of which you might not have considered.
We'd also like to thank our sponsor, AproDerm®, for all their help in putting these Skin Deep podcasts together. We couldn't have done it without them. So, until the next time, it's goodbye from George. Goodbye. And, as always, it's goodbye from me. Goodbye.