Kidney Cancer patients fare better with tumor removal only according to an article appearing in Health Day and Yahoo News. Kidney cancer patients who have only the tumor removed, not the entire kidney, have higher survival rates according to a new study. That research involves more than 7,000 Medicare patients with early stage kidney cancer who underwent surgery to remove either the entire organ or only the tumor and a small margin of healthy tissue around it. Early stage kidney cancers are becoming more common and are often discovered by chance when patients receive an X-ray or CT scan for an unrelated condition. According to Dr. David Miller, assistant professor of urology at University of Michigan Medical School, this study does not suggest that every patient with early stage kidney cancer should get a partial nephrectomy. The American Cancer Society estimates that nearly 65,000 people in the U.S. will be diagnosed with kidney cancer this year.  I'd like to thank the Kidney Cancer Association, the organizers and the participants in the meeting for the opportunity to talk today about outcomes for patients with locally advanced disease. Patients with locally advanced disease are patients who are at high risk of developing metastatic disease after nephrectomy. We'll talk about lymph node invasion, tumors that extend into the venous system, tumors that extend beyond the capsule into the perinephric fat, tumors that extend into adjacent organs and also the role of adjuvant systemic therapy. We'll begin with invasion of lymph nodes. Historically we saw this much more often, but nowadays with the advent of cross-sectional imaging CT scanners in most ERs, we're finding patients a lot earlier with smaller lesions. So this is a pretty rare event, maybe three to five percent. We also know the incidence is based on how well you look. If you do a limited lymph node dissection, you find less than if you do a more extensive lymph node dissection. Most patients with nodal disease will also have distant metastatic disease. We know that it's more common in patients with higher stage disease. This study at UCLA looked at 661 patients and patients who had T3 or T4 disease, so tumors that weren't confined to the kidney, there's a 20 percent rate of tumor in the lymph nodes. We also know this is more common with higher ferment grade in patients. This is another study at UCLA, two-thirds of patients who had lymph node negative disease had low grade disease, whereas two-thirds of patients with no positive disease had high grade disease, and this was also confirmed in other studies. So the important thing to realize is that patients with kidney cancer into their lymph nodes are more likely to die from cancer. This is a study out of the Mayo Clinic, a large study, and if you notice that the survival for patients who do not have lymph node invasion is significantly better than for patients who do have lymph node invasion. So we know that when we see this at the time of surgery, it's a bad thing. So within patients who have lymph node metastasis, we know that the histological subtype matters, the number of lymph nodes probably matters, as well as the lymph node density and extra nodal extension. So this is a study out of MD Anderson looking at patients who have papillary renal cell. Papillary subtype has actually a better prognosis if you have disease within your lymph nodes. As you can see here, the patients who had papillary disease had a 65 percent survival at five years compared to the patients who had clear cell, who did not do very well. This is another study at MD Anderson looking at the survival was dependent on the number of positive lymph nodes. They had 40 patients and looked at the survival, and it was much better if you only had one lymph node positive, or if you had more than one lymph node positive, you did worse. The concept of a lymph node density has also been shown to be predictive of how well a patient does after surgery. This is a study out of Italy looking at lymph node density. What the definition is, is the ratio of the number of nodes to the total of nodes involved. And this may be actually a better indicator of the quality of surgery, because in more sense of dissections you're going to get more lymph nodes and have a larger denominator. Total extension is also something people think is important. This is when the tumor extends beyond the lymph node, outside of the lymph node. And this study found that this was also an important variable. So the benefits of a lymph node dissection we think are two-fold. Number one, it provides more accurate staging so we can identify patients who are at risk of disease. And it also may provide a therapeutic benefit in patients who do not have distant metastasis and only have metastasis in their lymph node, and we may be able to cure these patients with surgery alone. However, with any surgical procedure there's always potential complications. We found in a couple large studies that the complications were generally not increased in patients with lymph node dissection at the time and effrectomy compared to an effrectomy alone. Nonetheless, we worry about things like bleeding, bowel injury, kyla societies, which is a large lymph leak after surgery, and ultimately death. Unfortunately, the available studies of patients with kidney cancer and lymph node dissection all have major limitations. All these studies are retrospective, so we're looking backwards with one notable exception. They're mostly with small numbers of patients. There's a selection bias anytime these patients underwent lymph node dissection. These are probably more healthy patients because we're doing a more extensive surgery. There's a lack of standardized template, so people don't agree on what type of surgery we should be doing. There's a lack of standardized pathologic examination. That can really skew the results. And there's also a lack of defined post-surgical treatments. So which lymph nodes need to be removed for kidney cancer? This is a key question. The initial studies were done in the 1930s and they were done on normal kidneys. In normal kidneys, the lymphatics follow the arteries back into the renal sinus and drain into the regional lymph nodes. However, kidney cancer is an abnormal situation. We know that kidney cancers make a lot of blood vessels that can alter the drainage patterns. We also know that the lymphatic drainage in the perinephric fat is not the same as in the kidney itself. So as the tumor spreads, this may actually alter the drainage pattern. So there's many different possibilities for what we will remove at the time of surgery. This shows the hyalur dissection and this just, this is kind of the most limited lymph node dissection we perform where we just take the lymph nodes that are right along the renal vessels. This is a little bit more extensive where we take some of the lymph nodes along the aorta or the inferior vena cava. And then the extended lymph node dissection. This shows the left side of the section where we take all the lymph nodes along the aorta from the diaphragm down to the bifurcation. And on the right side, we take all the lymph nodes that are next to the vena cava and also between the aorta and the vena cava. This is a little bit easier way to look at it. Let's see if my mouse works here. So this is the before and after picture of lymph node dissection. The large artery in the middle, the white structure, is the aorta that carries all the blood from your heart down to your lower extremities. And the vena cava is the blue structure where the white towel is, which carries all the blood back from your lower extremities to your heart. This is an extended lymph node dissection. You can see all the lymph nodes that have been removed from this patient. I'm sorry? They're on this side. You can see that white structure in the middle. It's hard to distinguish them from the fat in there as well. So here you can see the lymph nodes right here and kind of up. And this is the aorta here. And here's the vena cava going back. So we take all the tissue that's in the middle on these sides. So there's several studies which support performing lymph node dissection. This is a study at UCLA which looked at 900 patients who underwent lymph node dissection. And they saw there was a five month increase in median survival if patients had any type of lymph node dissection. There was no benefit for patients who didn't have clinically negative nodes, meaning if we couldn't see them on CT scan beforehand, there was no benefit to doing it. Most patients with positive lymph nodes were identified preoperatively, about 90%. This is a study out of Andy Anderson, which is just impressed looking at patients who had tumor in their lymph nodes, but did not have any evidence of distant metastasis. And this study showed, importantly, that some patients had a durable cure with surgery alone. So 22% of the patients, one of every five patients who had a lymph node dissection alone, were cured with a 44 month follow up. And again, most of these patients were identified preoperatively. So there are some studies that also question the benefit of lymph node dissection. This is a study out of Italy, looking at patients who had lymph node dissection and comparing them to patients who underwent an nephrectomy alone. Interestingly, the numbers are pretty small here, and most of them only have the only one patient who had a positive node on pathology. So these are probably not the patients who we think would benefit to begin with. But they found no survival difference. This is the only randomized trial. This is a trial out of Europe where they randomized patients to nephrectomy or nephrectomy plus lymph node dissection, and they found no difference in cancer-specific survival. Again, they were looking at patients who we probably wouldn't think would benefit from lymph node dissection to begin with, patient with small localized tumors. So in summary, do patients benefit from lymph node dissection? We think yes, and if you have enlarged lymph nodes on your preoperative imaging, or if you have interoperative evidence of lymph node disease, we do not think there's a benefit if there's organ-confined tumors or no clinical evidence of lymph node involvement on your preoperative and intraoperative assessment. And it's a possibility in patients who have advanced tumors and no evidence of lymph node involvement that these patients may get some benefit. Moving on to tumor thrombus. Tumors that invade the venous system. This occurs about 40 to 10% of the time. It can occur just in the kidney or move into the vena cava and all the way up into the heart. Only about 1% of them reach into the heart into the right atrium. Associated symptoms include lower extremity swelling, right-sided varicoseal, and that's a dilation of the veins around the man's testis. Pulmonary embolus, a blood clot in the lungs. Capit medusa, which is a dilation of the veins around your amylochus, your belly button. Protein present in the urine. You can also get advanced cardiac lung symptoms if it's a higher level thrombus. And non-function really is at the end. So there's many different classifications of tumor thrombus. This is from the Mayo Clinic. You can see as the tumor extends out of the kidney here, it can be just in the renal vein or can stand into the vena cava or eventually up and into the heart causing the most severe symptoms. So surgery in these patients is difficult. The first resection was reported in 1919. This was once considered at death science. Modern theories have the mortality of less than 5%. It does increase if the thrombus is above the diaphragm. 40 to 70% of these patients without mastectomy can be cured with surgery alone, and that's an important point. So it's important to do accurate imaging for these patients. We need to know the extent of the thrombus. This can be done with a multi-detector CT scan or MRI. While the patient is in surgery, we also do a transesophageal echocardiogram to make sure that the thrombus does not move during surgery. So what surgery entails for these patients, we'll start with the lower level thrombuses. We get control of the renal artery. We then ligate the lumbar veins. Here you can see in the first tile, this is the thrombus extending into the vena cava. We get control above and below and on the contralateral kidney. We then make an incision in the vena cava and remove the entire thrombus as well as the kidney. And then we repair the vena cava where we took the thrombus out. And then we breathe the sigh of relief and go home and everyone's happy. And when it gets higher, it requires mobilization and deliver, which occasionally requires including the hepatic blood supply. This is why these are more dangerous surgeries. In the level fourth thrombus, this actually may require open heart surgery, requiring a sternotomy and multiple surgical teams involved. It places patients at increased risk for bleeding, stroke, and heart attack. But it's important to realize that surgery can provide a durable cure in these patients without Mestac disease. So even though the surgery can be very complicated and difficult, some patients will survive and greater than 50% of these patients will survive with just surgery alone and not have any recurrence of their disease. There's some controversy because some studies show that the level of the thrombus is important. Other studies show that this just may be a result of low numbers or the failure to evaluate other predictors of bad outcomes.  Lymphs node involvement, sarcomatoid features, which are aberrant differentiation in pathology, as well as invasion into the blood vessel wall. And so this is one study, it's a small study which show that the thrombus level impacted survival. Development Mestac disease was seen in 10 to 49 patients with a thrombus below the diaphragm and four of seven patients who had a thrombus higher. This is another study which did not show the same thing, which showed that the level of the thrombus did not affect survival. This was a little bit larger study. And this is probably the largest study, almost 1200 patients from 13 different institutions in Europe. Again, they showed there was no difference based on the level in the IVC, but there was a difference for the patients who just had a thrombus in the renal vein compared to the patients who had a thrombus higher than the renal vein. So there's other factors which may affect survival in patients with venous invasion. This is a study at UCLA looking at 300 patients and they found that metastatic disease, either distant or in the lymph nodes was the strongest predictor survival, as well as the patient's performance status, how well they were able to do their normal activities. Invasion into the lymph nodes, sarcomatoid features, and perinephric fat evasion. We looked at our own experience at MD Anderson and found that in 605 patients over the last 15 years, similar things were predictive. So if you had a clear cell subtype that was actually better than if you had different subtypes, higher grade tumors did worse.  One other interesting thing we found was that microscopic tumor, which was present at the margin of resection in the vein, was also predictive of increased local recurrence and metastatic progression. So we think that it's important to resect the veins widely when at all possible. And this shows the top line here is patients who had negative margins on their vein. This is freedom from, these are patients who don't recur locally, and it's higher in patients who do have a positive vein margin. The same thing was true when we look at patients who progress to metastatic disease. If you have a negative vein margin, you do better than if you have a positive vein margin. So in summary, patients who have venous involvement are at a high risk to develop metastatic disease. Significant proportion of patients without metastatic disease when they first present can be cured by surgery alone, which is encouraging. Surgery requires careful planning and should involve experienced surgeons. And in general, the prognosis has not changed by the level of the thrombus, except in patients who have a renal vein thrombus only. So when the tumor starts to extend outside of the kidney into the perinephric fat, it also indicates a bad prognosis for the patient. This is a study looking at patients who had a tumor thrombus and about half the patients had thrombus alone and about the other half had thrombus in association with fat invasion.  So what that tells us is that fat invasion is a very bad prognostic factor. Again, this is a European study looking at almost 2,000 patients. They know that it's difficult to identify preoperatively. CT scans and MRIs don't pick this up. This is something that we pick up only pathologically. It's an important risk factor across all stages of disease and it affects survival in patients. It's something we have to consider after nephrectomy. So in summary, patients with fat invasion are at a higher risk to have disease recurrence and radiographic staging is inadequate to distinguish between patients with or without perinephric fat invasion. So when the tumors get out of the kidney and invade adjacent organs, you might also suspect this is a bad prognostic sign. This is a patient who has a kidney tumor, which is invading into the liver here. This is also something that's relatively rare. These T4 tumors, because kidney tumors are more likely to compress the other organs rather than invade into it. And these patients have a very poor prognosis with five years of rivals between five and 20%. Complete surgical excision is very important in these patients, including the involved organs if you're gonna give any chance of cure. So your organs and structures at risk, the adrenal gland, which sits on top of the kidney is one organ which is frequently involved. The posterior abdominal wall, the paraspinus muscles, which go along your vertebral column, the diaphragm, the spleen, the duodenum, the pancreas, and the colon, including the blood supply, which goes through the mesentery. This study looked at 38 patients with advanced disease. They found that the liver was the most common location for invasion. And their median survival was less than a year after resection. The only significant factor in these patients, which predicted death was a positive surgical margin. So this tells us that it's very important to take out the entire tumor as well as any adjacent organs in these patients. So can we predict this invasion preoperatively? This is a study out of MD Anderson, Dr. Margulis on Dr. Wood, looking at 30 patients with clinical T4 disease. They found that they were wrong more than they were right. As far as 60% of the time, it was downstage on final pathology. And their conclusion was that you cannot adequately predict a T4 tumor by preoperative and interoperative imaging. So when we compare adrenal invasion, which is a common area, a common plan that it invades to, compared to the perinephric invasion, this is a retrospective study of 1,000 patients. Almost 200 had perinephric fat invasion and about 2.5% had direct adrenal invasion. We found that survival was much worse with adrenal invasion compared to perinephric fat invasion.  So a summary on the adjacent organ invasion, kidney cancer compresses much more often than invades. So many times we think something in, while we're in clinic is invasive and we're wrong. There's a poor prognosis with invasion of adjacent organs. The majority of patients with T4 disease also have metastatic disease. Surgical resection, complete surgical resection is the only chance for a cure in these patients. And there's a lot of studies lacking in T4 disease, mostly because this is rare and it's hard to identify preoperatively.  So the next portion of this talk is on adjuvant therapy, systemic therapy an hour later. With the recent success of targeted agents and the dramatic responses and increases in patient survival, people are asking, is there a benefit to start patients who are high risk on these therapies right after nephrectomy? The definition of adjuvant therapy to be distinguished from neo-adjuvant therapy which Dr. Wood will be talking about later, is taking some form of therapy after complete surgical resection to decrease the risk of recurrence. And again, we think this is most indicated in high risk patients. We've seen earlier that high risk patients are these patients, patients with venous invasion, lymph node involvement, large tumors, invasion into the adjacent organs or perinephric fat involvement. So many different therapies have been tried. His recently local therapy, hormonal therapy, immunotherapy during the cytokine era, certain tumor vaccines and thalidomide have also all been tried and the short answer is none of these have worked. So there's no survival benefit to any of these therapies that have been seen. That really the big question is with targeted therapy, is there gonna be some benefit? And for the large part, the jury is still out. There have been many different studies ongoing and not much has been reported as of yet. So this is one trial called the Eryzer trial looking at monoclonal antibody G250. We're still waiting the results of this trial. One interesting thing that did come out of this trial is a PET scan which is specific for kidney cancer. This is very promising. This was reported last year's AUA. You can see this detects kidney cancer. A lot of times when things are very small, we have a difficult time detecting them on a conventional CT scan. This is not yet FDA approved. This is another trial, the Assure trial which finished accrual last fall. We're waiting on the results of this. This randomized patients to either synitinib enseraphanib or a combination with the placebo. One issue that we did see in these patients were that a lot of patients left treatment not because they were finished treatment and not because they progressed but because they were having difficulty with toxicity. So we have identified the fact that patients who take these targeted agents and don't have any metastatic disease have a significant adverse effect profile. This is another study which is expected to primary result in June 2017. This is the S-Track trial looking at patients with synitinib or a placebo. This trial is the Source trial. Again, the primary result is expected in 2012. Randomizing patients to either three years of serraphanib, one year serraphanib or placebo. This is the new GSK trial looking at posopenib in the adjuvant setting. And this is the newest trial looking at everolimus for renal cell cancer. Randomizing patients to either placebo or everolimus after nephrectomy. So in summary, adjuvant therapy we're currently waiting on the results of several trials which have been with agents which are shown promised in the metastatic setting. The toxicity for treatment is a major issue with a lot of patients stopping adjuvant treatment with targeted agents. Thank you. On April 16th this year, the National Cancer Institute is releasing the latest cancer statistics. Our statistics that we're currently releasing are from 1973 all the way to 2009. We are just now releasing data from 2009 and this reflects the complicated process that we go through to collect the data and ensure the quality of the information that we collect. So the 2009 information on overall mortality shows a continuation of the decline in mortality rates that we've seen since the late 1990s.  And together these four sites make up over 50% of the cancers that we find in our data set. All the mortality rates for all of those cancers in men and women for colorectal cancer and lung cancer are all decreasing and that's a continued decrease from what we've seen in the last few years. For incidents, for lung cancer, for both men and women it's decreasing. Prostate cancer is decreasing.   Cervical cancer, the rates are declining for both incidence and mortality in both groups. However, blacks remain at higher risk than whites for incidence and mortality. For breast cancer it's a complex picture where whites have higher level of incidence, risk of developing breast cancer, but blacks have higher mortality rates and the difference in mortality between white and black women has been increasing over time rather than decreasing. Lung cancer incidence is declining this year in both men and women and mortality is declining in men and women as well. However, the trends are very different for men than they are for women. Men have much higher rates but had a decline that started earlier and has continued. Women have had lower rates but they've been fairly level lately and have only shown a decline in the last few years. But with the 2009 data point we do see a statistically significant decline in incidence and mortality for women as well as men. These trends reflect patterns of smoking in the U.S. where men had higher rates of smoking than women and perhaps stopped smoking earlier. It typically takes a long time between the smoking behavior and changes in that behavior and when we see the impact on cancer incidence and mortality. The data that we base our statistics on are from the SEAR registry program. And SEAR stands for Surveillance Epidemiology and End Results. When we started SEAR back in 1975 we had nine registries but as time has gone on we've added more registries to get a better representation of the population as far as having adequate covers of different race groups, urban areas versus rural areas and now in 2009 we have 18 registries and 28% of the population. SEAR is also part of a larger national program of cancer registries that also includes the registries that are managed by CDC. Together they cover the vast majority of the United States and each state in the US has a cancer registry. SEAR registries are really a fundamental component of the data system for cancer research and monitoring and surveillance. They're really widely used by researchers, public policy and of course the public to understand their prognosis after diagnosis. It is also a basis of many different annual reports that come out. They really describe the cancer burden in the United States. It's part of the annual report to the nation which describes incidents and mortality for the whole US and it also plays an important role in reports such as the American Cancer Society's facts and figures where they estimate the number of cases that they expect to be diagnosed in the current year and the number of cases they expect to die in the current year for different cancer sites. Join us again next month for another edition of Kidney Cancer News. I'm Keri Konoski wishing you good health. Join us again next month for another edition of Kidney Cancer News produced by the Kidney Cancer Association. Find us on the web at kidneycancer.org. This is Dick Lashbroke speaking.


Good morning, welcome to CMC markets on Friday the 1st of May and this quick look at the week ahead beginning the 4th of May and before we get on to that, I think it's important to look back at the trading activity of the last few days. It's certainly been an interesting one given that we're starting to get an awful lot more visibility in terms of the overall outlook or the economic outlook in terms of the various economies, European economies, US economy, the UK economy when it comes to the economic damage caused by the lockdowns towards the middle and end of March and the likelihood of the significant economic damage that we're going to see when the April numbers come out and the Q2 estimates start to take shape. Despite all of the economic bad news, you would think that equity markets would have been a little bit held back by some of the data that's been hitting the wires over the past few days, but far from it. We've seen European stock markets finish April with their best month since October 2015, though they did finish April with a bit of a whimper falling sharply and I think this was largely down to the fact that the GDP numbers, the first quarter GDP estimates, the first ones from France, Italy, Spain and the US were much worse than expected. That still didn't stop the S&P 500, though, posting its best monthly gain since 1987, a gain of 10.7%, but I think a large part of the reason for the gains that we've seen in US markets, particularly the NASDAQ, was the fact that we've seen strong gains from the likes of Facebook, Amazon, Apple, Netflix, Alphabet and Microsoft. An awful lot of these companies do well as a result of people working from home. Certainly, Amazons performed quite admirably, easy for me to say, despite the fact that they're setting aside around about $4 billion worth of future profits in various areas to mitigate some of the coronavirus related expenses. Apple's earnings were actually slightly better for this Q2 than they were the same time last year, but these earnings announcements or these earnings expectations were revised down quite substantially from where they were earlier this year. Having said that, we've started May pretty much on the back foot. Earlier this week, the FTSE 100 went above $6,200, or you can see in the last couple of days those gains have pretty much gone. There is a good chance that actually for all the gains that we might have seen this week, we could well find that we actually finish the week lower. Certainly, looking at this daily chart here, we can see that we posted a key reversal day on the FTSE 100. There's a fairly even chance in the absence of European markets today, because it's May Day, that when they return on Monday, we could see a big gap lower in European equity markets. It's not hard to see why when a lot of initial GDP estimates for France, Italy, and Spain were in the region around about 4% and actually came in around about 5.8%, 5.8% in the case of France, 5.2% in the case of Spain, and around about 5% in the case of Italy. Despite the fact that an awful lot of the first quarter was actually not spent in lockdown, and some of these lockdowns happened towards the middle and end of March, these are enormous contractions when you consider that the lockdown has only encompassed around about three or four weeks of the actual quarter. So that gives you an indication of the extent of the economic impact that we're going to see as we come out of Q2, given the fact that only now in the next week or so are these lockdowns even going to show any significant signs of being relaxed, and even then any economic activity is likely to be very, very muted indeed. So the ECB is estimated that the GDP hit is likely to be between, in the worst case scenario, around about 15% annualized over the course of the next few months. Well, that's an enormous tier, and that's before you even consider the fact that the European economy was in a fairly weakened state leading into the crisis, let alone what it's going to look like afterwards. Having said that, what we've seen over the past couple of days is a sharp correction lower, and we've rebounded off the 50% Fibonacci retracement level of this down move in the FTSE 100. We did break above this 38.2 that had capped the price action up until earlier this week. We spilled out very rapidly towards the 50% level, but we've now slipped back. So I think really over the course of the next few days, you're going to hear an awful lot of commentary about selling Mayan Galway. Personally, I think that's a little bit of a trope if you like. I don't think it really bears up to an awful lot of scrutiny. But that being said, May generally does tend to be a little bit more cautious in terms of stock market performance, even if in past years we have seen some modest gains. Given the current context, I think it's going to be very, very difficult to see the potential for significant further upside, even if you allow for continued central bank monetary stimulus and the fact that they're likely to keep their foot hard to the floor. The economic impact, the earnings impact, I still don't think has been suitably factored in to the overall earnings outlook. That being said, the trend from the lows in March still remains very much towards the upside. So for all my skepticism about the sustainability of this particular rally, we still very much remain in by the dip mode simply because the fact of the matter is if we look at the correlations between all the relationships between these lows and these highs, we are still making higher highs and we are still making higher lows. So until such times as we take out these lows here around about 5,600 on the FTSE 100, I think we're very much in a case of by the dip on any pullback. That being said, we have posted a key day reversal on the FTSE 100. So we could see a little bit of further weakness in the short to medium term. Looking at the DAX, that's currently not being traded today because Germany, the German market is actually currently closed. So again here what we've seen was a big correction back from the highs that we saw on Wednesday this week of around about 11,200. We've reversed a good proportion of that. The likelihood is we are probably going to gap lower on Monday. You could argue that this is also an engulfing candle on the daily charts, so which would signal the potential for a test back to 10,190 on the German DAX when we come back next week. So I will be keeping an eye on that level on any move lower in the German DAX. The S&P is however open and despite the fact that the S&P 500 managed to post its best month since 1987, the gains that we saw in April still weren't enough to reverse the losses that we saw in March. We can see that born out if I change this particular chart here to a monthly chart and then we can display that thus here. So that was where, that's February, that's March. We haven't reversed all of them, but we've reversed a pretty good proportion of them. But if we go back to the daily chart we can also see a little bit of a reversal in the daily candle. It's certainly not conclusive in terms of the overall picture and actually you could argue that rather than being an engulfing candle, which it clearly is not, it could be construed as another variation on that dark cloud cover, which is the candle basically moves more than three quarters into the body of the previous day's candle. What's interesting is that we weren't able to take up 200-day moving average and as I've indicated on previous commentary, that was always going to be a key barrier going forward for US markets, notably the S&P and the Dow. So while we're below that, the upside barrier is going to be very significant I think in terms of any further gains over the course of the next few weeks and months. So while I've said we're very much in a by the dip mode, the upside is still going to be fairly limited in terms of where we're likely to go over the course of the next few months, unless or until we take out the 200-day moving average. That's going to be a very, very significant level for all equity markets as we look ahead. One of the notable takeaways from this week's key announcements has been the number of companies that have either cut the dividend or reduced the dividend or got rid of it completely, but also getting rid of their forward guidance as well. And I think it's entirely understandable the companies do that. I really don't understand why companies get punished for withdrawing guidance at the time when it's really difficult to really look more than three or four weeks ahead when it comes to the actual lockdown measures at the moment here in the UK. We don't know what the roadmap out of lockdown looks like. And against that backdrop, it's not perhaps surprising that companies feel that they can't give accurate guidance. And that's quite pragmatic, it's quite sensible. There have been some winners, Wreck-it-Ben-Kaiser earlier this week, actually raised their forward guidance for the rest of the year. But that's because they they came forward with a very good performance in their health and personal care divisions. There's Neurofen, Lemsip, Paracetamol generally, Detol and Lysol sales went through the roof. My only hope is that the people who stocked up on Detol, Lysol and everything else didn't take President Trump's advice to try and inject it. Otherwise, we would be having a different conversation. That being said, the employment, the data that we're looking at continues as we head into May. We've had UK manufacturing PMI today that came in at 32.6, slightly down from the 32.8 flash reading that we saw a couple of weeks ago. And as we head into Monday, we have the rest of the manufacturing PMIs from Europe. And while the slightly manufacturing activity has been slightly more manageable in terms of the European economies more broadly and the global economies more broadly, we've seen Japanese PMIs slipped to 41.9. The general manufacturing numbers that we're expecting out of Europe are probably going to be in the high 20s to low 30s. Still pretty horrible, but certainly nowhere near of the magnitude that we've seen from the services sector. And those numbers are due out on the 6th of May. Now, these numbers have been the complete train wreck. I mean, there's no sugarcoating it. We've seen record lows pretty much across the board, France, Italy, and Germany. And they point to sharp economic contractions as we head into Q2, extrapolating what we've seen in Q1 into Q2. And you're looking at 10, 15% contractions at the very least for Q2, when you have record lows of 10.2 in services for France and in the mid-teens for Italy, Germany, and the UK. I think the big data point for next week will be the US jobs data. US jobs data, we've also got a couple of rate decisions. We've seen the Fed earlier this week and the European Central Bank this week. The Fed painted a pretty dark picture of the economic outlook. But I think, encouragingly, they acknowledged that and they said that they would be monitoring the situation very, very closely and be ready to act further if economic conditions deteriorated further in the context of the stimulus that they've already undertaken to put into the global economy and the US economy more broadly. So let's start with the two rate decisions first. We've got the Bank of England. So in that context, let's have a look at the cable chart. The cable chart has actually been doing fairly well, largely as a result of a slightly weaker dollar. But what's quite interesting about this chart is, again, the 200-day moving average. I talked about that in the context of equity markets. It's equally as pertinent in terms of this cable chart here. The current rebound has stalled twice at the 200-day moving average, 1.2640.50. That's a very significant chart point. We did break above 1.25 earlier this week. We now need to hold above 1.25 to have any confidence that we're going to move higher. Certainly, if I look at cable and I look at the rally in equity markets, you could actually say there's a decent correlation between the two. One of the things I would say is actually the pound isn't anywhere near as weak as the footsick has been today. And it's not expected to be as weak as US markets are expected to be today. So there's a little bit of divergence going on there. More broadly, the pound has moved pretty much in lockstep with the rebound in global markets. The fact that it's not moving down maybe is a little bit encouraging as we look into next week. But may generally tends to be a weak month for the pound. So unless we're able to move above this 1.2650 level, there's a good chance we could revisit the lows all the way back here at around about 1.22 and a half. So I'll be paying particular attention to the cable chart over the course of the next few days because on a seasonal basis may generally tends to be a little bit weak. But certainly looking at this chart, the price action does look fairly positive. So we'll have to wait and see. There's no signs of reversal here in the same way that there has been in the FTSE 100 and the German DAX where we've seen potential key day reversals or dark cloud cover. So keeping an eye on that, the services PMIs, the manufacturing PMIs for the UK are likely to be weak. They're not like, that's not like to be a surprise. I think much will depend on what the US dollar does going forward and how bad next week's ISMs and ADP and non-farm payrolls reports are. We also have the RBA due to meet on the 5th of May. Now in recent comments, RBA Governor Philip Lowe has warned that the economy would shrink 10% in the first half of 2020. Again, in line with the equity market rallies, we've seen Aussie dollar rebound as well. This will be the first recession that Australia has seen in 30 years. It expects unemployment, the RBA expects unemployment to hit 10% by June with the outlook set to remain gloomy for the rest of 2020. Or you could actually make that sentence apply to pretty much every economy around the world. They're targeting the worst economic outcome since the 1930s. Again, you could use that description for pretty much anywhere. But it's important to see from this, even though we're seeing a little bit of a pullback today, we are still very much in an uptrend here. So I think unless we take out the 64 level on the Aussie dollar, then the current uptrend could well remain intact. You certainly could see a rebound from these sorts of levels on any pushed lower. Obviously, if we go straight through that level, then the likelihood is we'll probably see a correction level. But again, I think that will be really depend on equity markets more broadly. Euro sterling, let's have a quick look at that because I think that's quite an interesting chart. Finding some really decent support around about 86, 70, 80. That for me, I think is the line in the sand. I'm still more of a euro bear than I am a bull, even though we've seen Euro dollar move up above 109, 70 and looking to test 110. I still think 110 is a bit of a barrier on Euro dollar and it could well limit the upside, which means that the risk here, the fact that we haven't taken out 86, 80, if we're able to take out these highs here around about 87, 80 on Euro sterling. As long as we stay below there and more broadly, I think this series of highs here, this is likely to continue to range trade. I think Euro sterling is likely to remain fairly well sidelined. I'm still very much of the opinion that there's more downside risk than upside risk. But it's a question of really getting short of the right level. It got resistance around about 87, 80 behind that at 88, 70. I would certainly still look to play that from the short side. In terms of non-farm payrolls, it's going to be a big week for the dollar. Let's have a look at the CMC markets US dollar index because I explained how this worked in last week's video. Again, we are getting lower highs and we are finding a little bit of a base on the CMC dollar index in and around this series of lows around here, around about the 1030 area. So you've got low there, low there and low there. So there is a little bit of a little bit of a base forming there. But what's interesting is the fact that the rebounds are getting progressively shallower. So that does suggest to me perhaps that we could start to see a little bit of dollar weakness over the course of the month of May. And the only way that I would revise that opinion is if we really take out these series of highs that we saw in April. So the dollar index, the CMC dollar index is pointing to gradual dollar weakness while below this series of highs through here, which should be positive in the longer term for Euro dollar and cable. So very much a case of buy the dips on cable, very much a case of buy the dips on Euro dollar based on what the price action has been doing. And certainly the CMC dollar index does appear to support that. As you can see from here, we've got a series of highs through here around about 109.90, 110. We're around about there now. We've also got the 200 day moving average here. And we've also got these series of highs here. But overall, we're in a bit of a range on Euro dollar. I don't really expect that to change any time soon. So let's look at let's look at expectations for the US employment report. Well, the rise in weekly jobless claims has really been eye watering. I mean, 30 million Americans in six weeks. Now, the April employment report is only going to apply not to the last two weeks, but the first four weeks. And that's going to be around about 20 million jobs. Though it's quite likely the world could come in, the number could come in well above that and be closer to 22 million. The unemployment rate is also set to surge. We've also got the ADP report that's likely to see two million job losses as an estimate from the ADP. So you're looking in a region of around about 35 million Americans losing their job in the last six weeks. I mean, that's just eye watering really high. That's going to push the unemployment rate up to 20% over the course of the next month or so. We could certainly see it test that in the Non-Farm Playrolls report on Friday, which incidentally is also a UK bank holiday. I will be hosting a webinar to cover those numbers on that Friday, because I happen to draw the short straw, sadly. So what else do we have here? Bank of England rate decision, not really expecting too much from that. It will be Governor Andrew Bailey's first in the hot seat as he casts his as well as the NPC's eye over the wreckage of the UK economy in the wake of this coronavirus crisis. I'm not really expecting too much. Obviously, I think the economic outlook and inflation report is likely to pay into a very dark picture of the UK economy. But the UK central bank has already said that it remains ready to act to support the UK economy in conjunction with the UK Treasury. So they could actually go further in the range of assets that it might look to purchase. It's already buying corporate bonds, commercial paper. It might actually go a little bit further in its commitment to buy company assets to support businesses through this particular crisis. In terms of earnings, we've got numbers from BT Group, Intercontinental Hotels, ITV, Walt Disney and Uber. Uber, well, obviously the cab business is not doing particularly well. But in terms of Uber Eats, you would expect that business to do quite well. Unfortunately, it only makes up a very small amount of Uber's overall incomes. The rally that we've seen in Uber shares thus far has stalled at the 200-day moving average. So keep an eye on that in the context of the numbers that are due to come out for Uber. I'm just going to change the colour of that so it pops a little bit more. Because that light blue is not particularly eye-catching. So I'm just about to change that. There we go. That's slightly better. So 200-day moving average around about $32. Keep an eye on that for Uber. Not really expecting anything eye-watering from there. Walt Disney. Now that's going to be an interesting stop because of the success of Disney Plus that we've seen over the course of the last few weeks. That launched here in the UK on the 24th of March, pretty much just a few days after the lockdown took place. Now we've seen a decent rebound in Disney shares. The problem that Disney has is that it's having to contend with the closure of its theme parks, movie production, and the length of time they may have to wait until they can open and restart. So even then, footfall is likely to be much lower as consumers avoid large-scale events in crowded places. So while a new streaming service Disney Plus is likely to do well, it's unlikely to fill the gap given the small margins and the fact it's also one of the cheapest and the content is quite limited in its scope. Netflix have already said that any subscription boost is likely to be fairly short-lived. So I think from that point of view, the upside in Disney shares could well be fairly limited even if they were to be earning expectations into continental hotels. They're pretty much in the same boat, they own Holiday Inn and Crown Plaza. They're going to be in the same boat as the airlines in terms of how they do. They've posted some decent rebound, but here we've seen a very bearish reversal on the daily chart. Having said that, we saw one of those here and it didn't really amount to much. So again, it's in a nice little uptrend. Draw a line through those lows if we break below this key support in and around 3,300, which is around about these lows last Friday, then we could see a bit of a correction lower. But certainly in terms of intercontinental hotels, they've already said they expect to report the first quarter revenue per room will fall 25%, with 55% of that decline taking place in March. So you could argue that an awful lot of that is already priced in and the greater China region is expected to show continued improvement as China recovers from its own lockdown. We've also got BT Group. Obviously, BT Sport just shelled out a huge amount of money for Champions League. Well, there's no football, so they're not really going to see the benefit of that. And there is speculation that they could well see a cut to their dividend. We've already seen Shell surprisingly cut their dividend and BP not cut their dividend in the past week or so. So certainly wouldn't want a dividend cut on the part of BT Group, given the fact that they have underlying net debt on the up and they'll need to do something to try and offset that. It's at a record £18.2 billion. So it could become the latest company to cut its payout in the face of the uncertainty around coronavirus. So that's it for this week. Oh, just have a quick look at Brent, seen a decent rebound over the past week or so. Is there further to go? I think it's very difficult to say with Brent at the moment. It's becoming very, very difficult to trade. What we have seen, I think, is if we do get a rebound, we could retest the highs, sorry, we saw in the middle of April, given the fact that production cuts that were agreed last month, kick in today. So keep an eye on that. And Gold has not been able to sustain that move above $1,700 an ounce. Not overly concerned by that, as long as we're able to hold above these lows here, rather, from the 21st of April, then the likelihood is we'll continue to see a move higher than the Gold price. So that's it for this week. Ladies and gentlemen, thank you very much for listening. Before I sign off, just quickly bring back the disclaimer so that I can keep my good people in compliance happy. Thank you very much for listening. Hopefully, you will all have a very nice weekend. And I will talk to you all this time next week when we cover the non-farm payrolls report. Thank you.