Pancreatic Cancer 2022 Summit
The Pancreatic Cancer 2022 Summit is a repeat summit (previous summits held 2014 and 2017)
As a repeat summit, data comparison to previous years and project updates will be included
The Summit will be held Friday 26 August
Location: RACV City Club, 501 Bourke St, Melbourne, 3000
Time: 08:15am for a 09:00am start
1:30pm finish with lunch till 2:30pm
Tea and coffee will be provided upon arrival. Please arrive before 9:00am for registration
Covid safe check-in procedures may apply
IN THE EVENT OF COVID RESTRICTIONS THE SUMMIT WILL BE HELD ONLINE
For enquiries regarding Victorian Tumour Summits please contact the NEMICS office on (03) 9496 3322 or email <NEMICSadmin@austin.org.au>
Clinicians will be contacted by their local Integrated Cancer Service for registration closer to the date of the event
Carer perspective: pancreatic cancer
Cherie Dear is a carer for her husband Paul, who was diagnosed with metastatic pancreatic cancer in September of 2020 and began chemotherapy. Paul underwent life saving emergency surgery for internal bleeding in June of 2021 where most of his tumours which were causing the bleeding were removed. He had subsequent surgery to remove tumours from his liver. After seven months with a high quality of life, Paul developed pleural metastases. Cherie and Paul have four children.
I think that generally, within the health system, there is a tendency to be cautious and pessimistic rather than give patients any slight chance of optimism. In Paul’s case, being stage four meant that he was on palliative chemotherapy only. During his treatment we were told that his tumours were stable. He wasn’t getting sicker and his tumour markers were dropping, but his scan reports only ever said that his tumours hadn’t changed much. Every time he had a scan, and you’re living for those scans, they came back with little change. His oncologist kept us motivated by reminding us that a 'stable disease is a good disease.'
When Paul was first diagnosed with metastatic cancer we were told that surgery would not be an option for us, so we put it straight out of our minds. And then along the way, I kept reading as much as I could about pancreatic cancer. I came across a surgeon in Melbourne who also conducted their own research. We met with them to discuss the research. As an aside, the surgeon indicated they had looked at Paul's scans and thought they might be able to operate in the future. We didn't really think a lot about that because [initially] we’d been told that Paul was inoperable.
Paul was in hospital after vomiting copious amounts of blood. The hospital couldn’t tell us what was causing it. I reached out to the surgeon again to get their view, and they said, ‘I've looked at the scans and I know what's causing the bleeding.’ Left long enough, it would have killed him. Whilst Paul was preparing for surgery he had another nearly catastrophic bleed, which led to emergency surgery. Subsequent histology reports indicated that he’d had almost a complete response to chemotherapy. We were shocked because scans never, ever indicated this and if they had, we may have had more hope. It makes me wonder how many other people having chemotherapy are actually getting a better response than scan reports indicate. We wouldn’t have known ourselves if Paul hadn’t had emergency surgery and the tumours were biopsied. After this, he was able to have further surgery to remove more tumours, most of which were also inactive.
We were well aware that the cancer could recur. We knew that, but because of that surgery we were given another Christmas with our children and more time. And, not just more time with a really reduced quality of life. Paul was really, really well and people were telling us they've never seen him look better. How does that happen from a stage four pancreatic cancer diagnosis? Looking fit and healthy and enjoying a really high quality of life? We’re so grateful for that surgery that we were originally told would never be possible. But, I have a real concern about what would have happened if the internal bleeding hadn't happened and I wonder how many other patients are out there in a similar situation. Perhaps getting a better response to the chemotherapy than what scans can reveal and [who] could be given the same opportunity.
We get a strong view from the medical fraternity that because it’s a stage four diagnosis, and especially for an aggressive cancer like pancreatic, there is always caution and basically an assumption that the end is near. We know that any treatment, even surgery is unlikely to be curative, but even if that is the case, patients deserve the opportunity to pursue treatment that may extend life, especially if it allows them to also enjoy improved quality of life, which is what Paul got. After his surgery his markers were within the normal range. He was able to enjoy seven months without active treatment with an extremely high quality of life. When he was first diagnosed we never envisaged a time when this might be possible.
Update Tue 14 Dec 2021
Consumer perspective: pancreatic cancer
Helen is married to Geoff and has been involved in his treatment since his diagnosis in 2019.
When Geoff was diagnosed he did not have any obvious symptoms except some breathlessness. Following an ECG, his skin had a yellowish tinge and two days later he was very unwell. It was a Saturday and Geoff said, ‘I’ll see the doctor on Monday’. He had never looked so ill and I insisted he see the GP that day. The doctor ordered blood tests and an urgent CT. The scan was scheduled for Monday but the next day Geoff was so sick I called an ambulance. He had a CT scan almost immediately. When the doctor came in with the results, the nurse behind him was visibly upset and the doctor said, ‘I’m ninety-nine percent sure it’s cancer.’
We were utterly shocked and knew nothing about pancreatic cancer. Unlike breast cancer, for example, it gets little or no publicity. Within days I was advised to get all our affairs in order, cancel upcoming travel plans and that the coming Christmas may be his last. Geoff was in hospital for three weeks and very unsure about having chemo. Two days before it was scheduled to commence, he was so conflicted I didn’t want to leave him but it was our granddaughter’s graduation that evening and he urged me to go. I spoke with the charge nurse and told her how worried I was. She said, ‘Go, I’ll talk to him.’ She spent a long time with him explaining the treatment and what to expect. The following day he agreed to go ahead.
I didn’t want Geoff’s prognosis to be sugar-coated, because we had to deal with the reality. His surgeon was very straight forward and honest with us. He went to great lengths to outline the whipple procedure and the risks but was cautiously optimistic, despite the cancer being 90% borderline. He was so patient in explaining everything, including the survival rates and what to expect after surgery. It took several consultations before Geoff decided to have the operation. In contrast, some other clinicians involved in Geoff’s care were less forthcoming. Questions I asked would be answered back to Geoff, as if I wasn’t there. I really needed them to be more inclusive of me – to understand I was Geoff’s primary carer. It’s true that both patient and partner go through the illness.
One of our clinicians asked Geoff at one appointment if he was doing ok psychologically. He said, ‘Yeah, I’m ok’ – typical of him. I said, ‘He may be ok, but I’m not, actually. I feel I need to talk to someone.’ They seemed a bit surprised but said they would refer us to the local home hospice. I heard nothing for three weeks so I contacted the home hospice directly and thankfully they allowed me to self-refer. It was so reassuring to have them on board, to outline the services they would provide and talk about such things as end-of-life plans. Even a phone call can be reassuring during such a stressful time and help a carer to cope with the worry and emotional turmoil.
Clinicians need to be aware some patients, especially older ones and particularly men, are reluctant to question specialists or to discuss mental health. I was incredibly lucky my daughter-in-law, who works in cancer health, acted as our advocate. She joked that the hospital staff thought, when seeing her coming down the corridor, ‘Here we go again.’ But she was amazing – talking from a knowledge base with the nurses about medication, asking pertinent questions, helping me source information and support, and stressed that I had a right to be informed about what was happening. I would have been lost without her. I believe patients really need a dedicated pancreatic cancer specialist nurse, as is the practice in some other states. They can be the first port of call between appointments. I was so lucky to have a family member to help me but not everyone has that.
There has to be an element of trust involved in pancreatic cancer treatment between patients, their carers and multidisciplinary teams. You need confidence that your loved one’s case is regularly discussed at meetings and the MDT is considering all viable options, including clinical trials. Without regular feedback you have no way of knowing that this is happening.
After three months’ chemo, the whipple procedure mid-2020, followed by another three months of chemo, Geoff was declared in remission. He gradually recovered and did well until mid-July this year, when he began to feel unwell. He saw his oncologist in early August but apart from the CA19.9 marker slowly increasing, a number of scans and a gastroscopy showed no cancer. It was not until an MRI in October that it was confirmed the cancer was back. He has elected not to have any further treatment apart from palliative pain management and is going for quality over quantity. I asked him recently if he regretted all the chemo and surgery. He gave it some thought then said, ‘No, because if I hadn’t, I wouldn’t be here now.’
Update Mon 4 Oct 2021
National upper gastrointestinal (GI) cancer patient support services – PanSupport®
The support networks and services that exist for more common cancers are lacking for upper GI cancers. As a result, access to information and ease of treatment pathways are compromised.
In recognition of this need, leading not-for-profit Pancare Foundation – an organisation committed to inspiring hope, raising awareness, supporting families and funding research for upper GI cancers – launched PanSupport in 2020 to help provide specialised support to the 12,400 Australians diagnosed with an upper GI cancer each year. Shannon Gleeson, Pancare Foundation’s Upper GI Specialist Cancer Nurse, has seen a steady increase in demand for PanSupport services and programs, with a 250% increase over the past six months.
Dedicated upper gastrointestinal cancer support for patients and their families
Clinicians play an essential role in ensuring that those living with an upper gastrointestinal (GI) cancer receive the best care possible and Pancare Foundation currently supports a vast network of health professionals and researchers to enable Australians affected by upper GI cancer to receive the latest evidence-based information and access personalised supportive care through our PanSupport programs. Shannon encourages clinicians to let their patients know about PanSupport. 'By referring your patients to the PanSupport service, you are ensuring that they have access to a successful support program when they are vulnerable and overwhelmed. The PanSupport team can help address patient and carer concerns, provide early intervention, reduce stress, and improve outcomes.'
PanSupport can help patients engage with experienced upper GI cancer care support staff, find dedicated information on living with cancer, access counselling support, obtain financial assistance and connect with others at our support groups.
PanSupport resources and information
Through the Pancare Foundation website, health professionals and patients can access a variety of resources and dedicated information on living with pancreatic, liver, stomach, biliary or oesophageal cancers – including how cancer is diagnosed, treatment options, managing symptoms, the importance of diet and exercise, clinical trials and practical ways to support emotional and physical wellbeing.
The PanSupport telehealth service enables both patients living with cancer and their carers to speak with the Pancare upper GI specialist cancer nurse or patient support manager, regardless of location. Our team can help patients and carers understand their diagnosis or treatment options, provide resources and information, or connect patients and carers with cancer services in their local area.
Pancreatic cancer patient Keon has accessed PanSupport services since diagnosis. 'Pancare Foundation have been a great source of support during my treatment with pancreatic cancer. Through their PanSupport program, I’ve had access to their specialist cancer nurse, Shannon, who has helped me access treatment options and kept me motivated and determined to beat this disease. They’ve connected me with other patients through their support groups which has allowed me to learn from other’s experiences. It has allowed me to provide support to others and has allowed me to remain positive about my situation.'
In addition to specialist nursing support and practical support, a PanSupport counsellor is available for 45-minute telehealth counselling sessions to help patients and carers alike in processing the emotional challenges of living with cancer. Our qualified counsellor can help patients and carers cope with a diagnosis and support those caring for loved ones.
PanSupport facilitates a range of online and in-person cancer support groups. These groups provide forums for people affected by upper GI cancer to come together in a supportive environment to share their lived experience, providing patients and carers with the opportunity to talk about their experience.
Shannon is hopeful that more upper gastrointestinal patients will access the PanSupport program. 'We want all people diagnosed with an upper GI cancer to know that there is support available, there is always hope and we are there to support them every step of the way – we are only one phone call away.'
To learn more about Pancare Foundation and our PanSupport program, or to discuss any specific support care information that your healthcare team many need to enable referral to Pancare services, please contact Sarah Collings, <email@example.com>.
Update Thu 17 March 2022
Pancreatic synoptic reporting goes nationwide
Charles Pilgrim, SMICS and NEMICS
The collaborative pancreatic cancer resectability project, led by SMICS in partnership with NEMICS, was headed by project leads Anna Maciejewska (SMICS) and Nadia Ayres (NEMICS) and clinicians A/Prof Charles Pilgrim, A/Prof Samantha Ellis and Dr Mark Goodwin. The project began in August 2019 and the pilot ran 15 October 2020 – 30 September 2021, trialling a synoptic template for use by radiologists reporting CT scans. It is hoped the synoptic template will ultimately allow for more accurately tailored treatment options and improve outcomes for patients with pancreatic cancer. A grant to take the trial nationwide was awarded in January 2022.
Pancreatic cancer has most commonly already spread to distant sites when it is first discovered, but for those in whom it has not, the tumour itself may be categorised as ‘resectable’, whereby patients may proceed to surgery, ‘locally advanced’, where surgery is not possible, or an intermediate group known as ‘borderline resectable’. The optimal treatment plan for each of these three stages is critically determined by the anatomical extent of the tumour visible on CT scans.
The pancreatic cancer resectability project partnered with the Upper Gastrointestinal Cancer Registry (UGICR) to enable central data collection of synoptic radiological reports outlining these resectability states. Following the pilot, a Medical Research Future Fund grant application was submitted by UGICR. The ‘SCANPatient’ study proposal will test the application of the structured radiology report in distinguishing patients who should receive chemotherapy before surgery versus surgery alone, in order to optimise their pancreatic cancer care based on their resectability classification.
As Nadia Ayres, project lead at NEMICS says, ‘It’s about improving care. The synoptic report supports clinicians by providing documented anatomical detail to develop a well-informed treatment plan for their patient. And with more clinical information available, the scope of possible treatment options for patients is improved. Having an optimal treatment plan is really based on having as much accurate and detailed information as possible at the time of diagnosis.’
For Anna Maciejewska of SMICS, the project was the perfect vehicle to demonstrate how the findings of a tumour summit can be used as a focus for a discrete piece of work to achieve large-scale and longer term outcomes. ‘The 2017 pancreatic summit, which was hosted by the ICS network, facilitated the conversation that identified the gap in the definition of borderline cases. The ICS were integral to hosting the original conversation and then two ICS entities undertook the work to bring about a focussed, measurable result. It also showcased our ability to work in close collaboration with each other and outside entities, such as UGICR and clinicians across disciplines. For me personally, the challenge lay in bringing a solution that was sustainable and attractive to the end users. There is power in combining efforts and talents and I think we all enjoyed working towards a common goal. And on the days that our hopes faded, I kept saying we will find a solution, and we did.’
A/Prof Charles Pilgrim agrees there is now an opportunity to trial what worked well locally on a national scale. ‘The last time there was a truly nationwide trial of this magnitude in pancreas cancer was probably back in 2012. We think this grant will help identify at a nationwide level what was identified at a statewide level – that there are probably more patients with borderline resectability than we currently recognise, but even if it doesn’t... at least we will all be speaking the same language and know we are using a uniform system that is based on the international guidelines defining borderline resectable pancreas cancer.
I thank and acknowledge the Department of Health for being supportive in getting the pilot up and going and having the vision to recognise the point we identified during the summit was worth pursuing. I think this has the potential to impress internationally - if an entire country can adopt international guidelines and agree on using a structured method for describing pancreas cancer, I think it’ll be a benchmark almost of what’s possible and what we should be trying to achieve on a world stage. That is to be able to compare, not just within Australia, but from country to country what the best treatment plans are for patients with different cancer stages. So, I think it has the potential to really put Australia in the spotlight for improving the care of patients with pancreas cancer.’
A/Prof Charles Pilgrim has authored an article on the pilot, which has been submitted to the ANZ Journal of Surgery.
Update Tue 3 Aug 2021
Pancreatic resectability project update
SMICS and NEMICS
The pancreatic resectability project is an opportunity to shift patient outcomes by consistent and standardised radiological synoptic reporting, in this way providing valuable inputs into MDM discussion for patient surgery and therapy recommendations. The pilot conducted at Austin and Alfred Health concludes 30 September, 2021. A final report is currently planned for submission to the Department of Health in December. The steering committee will meet in September to look at the transition of the pilot at the two health services and the way forward in terms of the possible adoption of the tool at other key pancreatic centres that hold a HPB MDM.
To date, the synoptic tool has been applied to over 80 patients and participating radiologists certainly perceive value in using it to systematically and consistently assess CT scans. Positive feedback has been received from at least two surgeons associated with the project.
One of the key challenges of the project is associated with collecting the synoptic report data for externally generated CT scans at a local health service. For the purposes of the pilot the project team worked in partnership with the UGICR – radiologists can currently complete a synoptic report template hosted by the registry. A key consideration for the future includes the completion of a synoptic report at a health service, given that a significant proportion of CT scans considered at HPB MDMs are generated by outside providers, and therefore do not reside in local radiology information systems.
Abstracts of the project are being prepared for COSA and a presentation on the pilot will be held at the Pancreatic Cancer 2021 Summit in October.
Update Tue 17 Nov 2020
Defining pancreatic cancer resectability
Dr Charles Pilgrim
Agreeing upon a standardised definition of what constitutes surgical resectability is a critical area of need in the treatment of pancreatic cancer. A pilot of a project aiming to develop a synoptic report defining resectability status in pancreatic cancer commenced at two health sites, The Austin and The Alfred, in October 2020. This pilot will run for one year. The project was born out of discussion on areas of deficiencies in the statewide data presented at the Pancreatic Cancer 2017 Summit.
Clinicians from across Victoria gathered at the Summit to identify unwarranted variations in clinical practice and outcomes that could be addressed through statewide action. One of the prioritised variations was the recognition that administration of systemic therapy for patients with pancreatic ductal adenocarcinoma (PDAC) is critical to their longterm outlook.
In a series of post-Summit working party meetings, the importance of patients actually receiving effective systemic therapy was discussed. Delivering chemotherapy prior to surgery for patients with borderline resectable PDAC was acknowledged as an emerging and promising new approach. Central to considering this ‘neoadjuvant approach’ is the delineation of what constitutes borderline resectable disease versus what is clearly resectable or alternatively, what is clearly locally advanced and unresectable. The working party agreed on the importance of classifying pancreatic cancer using this terminology as it informs optimal treatment pathways and is more useful in clinical decision making than the AJCC (American Joint Committee on Cancer) pathological staging manual definition, only available following surgical resection.
A statewide audit to investigate the use of systemic therapy was conducted. The audit confirmed inconsistencies in the classification of borderline resectable (BR) disease. The Summit working party suggested that agreeing on and adopting a common statewide definition of resectability in PDAC would would be critical to minimise variation in care and help ensure appropriate and consistent management of patients across Victoria. It would also assist with identifying patients for clinical trials and reporting treatment outcomes.
Subsequently, SMICS and NEMICS worked together to propose a project in response to the identified need to agree on a statewide definition of BR pancreatic cancer. A project steering committee and working group representing pancreatic surgery centres across the state was established. The working group proposed the use of the ‘International consensus on definition and criteria of borderline resectable pancreatic ductal carcinoma 2017’1 and these guidelines were unanimously accepted. However, the need to embed this into clinical practice remained, and clinical consultation determined that a standardised CT reporting template for radiologists was required. This would allow accurate reporting according to the agreed guidelines by radiologists for surgeons at MDMs, and therefore appropriate treatment decisions for patients.
Working group members were involved in the co-design of a template for clinical reporting. Development of the template was complex and required a true reflection of the process radiologists undertake to determine the disease status. The current pilot will allow for further refinement, should it be required, to ensure sufficient accuracy of the template.
In undertaking the tool development, the radiologists showed a preference towards an electronic solution. The application REDCap was chosen as a suitable platform. As the resectability status is already collected and stored by the Upper Gastrointestinal Cancer Registry (UGICR) and is also collected via REDCap it became obvious that the storage of patient project data with the UGICR was appropriate. However, there was considerable oversight required regarding patient information security before the pilot could proceed.
Another element of the process was the integration of the template into health service sites and a number of complexities needed to be overcome for this to be implemented.
Should the pilot prove successful, there will be the option of offering a tested and verified template to Victorian health services. Further consideration of the location for the storage of patient data may however be required.
It is hoped that the agreement to use the 2017 international resectability guidelines and implementation of the new CT template will help Victorians with pancreatic cancer by:
- assisting in complete, pertinent and accurate reporting of disease staging and resectability status in patients with non-metastatic PDAC
- assisting multidisciplinary teams in the decision-making process for the management of patients with non-metastatic PDAC
- minimising futile operative procedures from being performed on patients with locally advanced disease
- leading to timely and appropriate referral to palliative care.
- Victorian Tumour Summits has produced the Pancreatic Cancer 2017 Summit Prioritised Variations video. This video is a resource for clinicians, by clinicians. Featuring Drs Charles Pilgrim and Belinda Lee.
Pancreatic Cancer 2017 Summit in pictures
What was the Pancreatic Cancer 2017 Summit?
Diagnosis and treatment of pancreatic cancer has a significant physical and emotional impact on patients and their loved ones. The Victorian Tumour Summits are clinician led forums seeking to identify unwarranted variations in tumour based clinical practice and cancer outcomes that could be addressed through state-wide action. Seventy stakeholders from across Victoria gathered on November 24 to discuss variations in care and identify opportunities for improvement.
Watch the presentation by Professor Robert Thomas:
Watch the presentation by Ms Kathryn Whitfield:
Watch the data presentation by Dr Charles Pilgrim:
Watch a summary of the day by Dr Charles Pilgrim:
What is Data Telling Us?
- One-year relative survival increased from 27% to 34% between 2011-15.
- Post-operative mortality is low by international standards: 2.1% (30 days); 2.7% (90 days); 19.7% (1-year).
- A decrease in the number of Victorian hospitals conducting low volumes of pancreatic resections (1-3 per year) from 10 to 4 between the 2014/15 and 2016/17 financial years.
- Only 5% of patients who had curative surgery for non-metastatic pancreatic ductal adenocarcinoma had neoadjuvant therapy.
- 23% of patients who had curative surgery for non-metastatic pancreatic ductal adenocarcinoma did not have adjuvant therapy.
- The state-wide average for documented multidisciplinary meeting discussion was 70% in 2013-15.
- 75% of deaths for pancreatic cancer occurred during a hospital admission.
Of these variations, several were prioritised for further investigation and action:
- Adjuvant therapy – 23% of patients who had curative surgery for non-metastatic pancreatic ductal adenocarcinoma did not have adjuvant therapy.
- Multidisciplinary meetings – 70% was the state average for multidisciplinary meeting discussion in the years 2013-2015.
- Palliative care – 75% of pancreatic cancer deaths occur in hospital.
The clinical working party reconvened in March 2018 to revisit outcomes of the summit discussion and review additional evidence of prioritised variations.
Further work has occurred to analyse cases who did not receive adjuvant therapy. It appears patients who underwent surgery in the NEMICS & BSWRICS regions were less likely to receive adjuvant therapy. Compared to patients who did receive therapy, these patients were:
- Spent a greater number of hours in ICU during their surgery episode
- Had a longer length of stay during their surgery episode
- Had a higher 30- and 90-day mortality rate following surgery
Of these patients, 26% were less than 70 years of age, had no known comorbidities and were alive 90 days following surgery.
In relation to multidisciplinary meetings, the working party highlighted the need for up-to-date data to determine the cause of the discussion rate for pancreatic cancer patients. The group recognised it is likely that stage IV patients are not discussed due to limited multidisciplinary meeting resources.
Data on hospital deaths was considered to indicate possible issues with the current usage of state-wide palliative care services. Based on palliative care clinical feedback from studies on other cancer types, timeliness of contact with palliative care services could have a positive outcome on reducing the percentage of patients with pancreatic cancer dying in hospital. A focus for action has yet to be determined.
As of 2018 most clinical teams caring for pancreatic cancer patients in Victoria are aware of the variations in care prioritised at the summit, as well as the upcoming optimal cancer care pathways implementation program. If you have had an opportunity to discuss how these variations relate to the care you provide and how you would create a measurable investigation, contact Mirela.Matthews@austin.org.au on (03) 9496 3455.
What is Pancare?
The Pancare Foundation was established to be the long-standing voice of those affected by pancreatic, liver, biliary, oesophageal and stomach cancers. Pancare work to save and improve lives through public awareness, support, education and research.
Pancare has produced a series of guides for patients and carers as they undergo their cancer journey:
- Pancreatic Cancer Patient Handbook - provides a general introduction to pancreatic cancer, information on tests and investigations that help confirm a diagnosis and provides an overview of possible treatment options and the wider impact of the diagnosis.
- Pancreatic Cancer Dietary Handbook - highlights important information about managing your diet if you have or have had pancreatic cancer.
Download patient and carer handbooks here https://www.pancare.org.au/support/patient-care/
For hard copies contact Pancare on 1300 881 698 or email firstname.lastname@example.org
Pancreatic Cancer Summit working party
Dr Rob Blum
Prof Christopher Christophi
Mr Dan Croagh
Mr David Deutscher
Mr Adrian Fox
A/Prof Peter Gibbs
Mr George Kalogeropoulos
Dr Richard Khor
A/Prof Brian Le
Dr Belinda Lee
Mr Mehrdad Nikfarjam
Mr Charles Pilgrim
Dr Babak Tamjid
A/Prof Niall Tebbutt
A/Prof Ben Thomson
A/Prof Valery Usatoff
Prof John Zalcberg
Ms Mirela Matthews
Ms Amy Sutherland
Ms Megan Dendle
Mr Luc te Marvelde
Ms Ella Stuart