Transcription:
Leonard's List 2020

Dr. John Leonard:  Welcome to Weill Cornell Medicine CancerCast, conversations about new developments in medicine, cancer care and research. I'm your host, Dr. John Leonard. And today, we will be discussing the Leonard List, an annual review of the 15 most interesting lymphoma-related abstracts to be presented at the 2020 annual meeting of the American Society of Hematology or ASH. This is our third annual podcast episode where we've covered the Leonard List.

But to give you sense of this, if you're less familiar with ASH, the American Society of Hematology is one of the largest meetings around blood cancers in the world that's held annually in December. This year, it is held virtually not surprisingly. And for the past several years, I have put together what I've termed the Leonard List, which is a daily countdown of 10 abstracts or summaries over 10 days of some of the most interesting abstracts. The criteria for this are really things that get my attention, things that I think will be relevant to practice or things that are exciting and that people should keep an eye out for in the future. So there aren't other strict criteria for this, really just things that kind of strike my fancy.

And as a bonus for our podcast listeners, we have generally given five extra abstracts at the end, which I don't put on Twitter. Generally, this countdown I've done on Twitter over 10 days, 10 abstracts one a day. But since you're here, you'll get to hear them first before we get too far into the countdown and you'll also get the five bonus abstracts for my thoughts before we get anywhere. So hopefully, you'll find this interesting and you can feel free to agree, disagree, put your own ideas out there. If you follow me on Twitter, feel free, as you see the countdown, to give your thoughts and, otherwise, let's get right into it.

So we're going to count down kind of backwards. And again, these are abstracts, as you may or may not know. Each presentation at the American Society of Hematology meeting like many meetings, researchers, investigators send in a few months in advance a summary, basically a page typewritten summary of a research project that they've done. This could be laboratory research, epidemiologic research, clinical trials, anything relating to blood and blood cancers. In the case of ASH, I'm focusing on lymphoma specifically, but this covers the gamut from hemophilia to leukemia to STEM cell transplant to thalassemia to lots and lots of basic science and epidemiologic studies.

And so these abstracts either get presented as an oral presentation and the most exciting of those are at the plenary session where everyone at the meeting can attend and hear these highest impact presentations. There are oral sessions focused on different topics. There are typically poster sessions there where the data are presented on obviously a poster and people walk around and comment and then others are simply published. And this year, it's a little bit different because it's online, but that said, a lot of interesting data.

So again, this is presented by Dr. Alex Herrera from City of Hope and colleagues. It's entitled Consolidation with Nivolumab and Brentuximab Vedotin after Autologous STEM Cell Transplantation in Patients with High-Risk Hodgkin Lymphoma. So the key here is that most patients with Hodgkin lymphoma who have relapsed disease go on to get an autologous STEM cell transplant after they get some therapy, a second line therapy, typically to hopefully get into a remission. And then they get an autologous STEM cell transplant to try to consolidate that remission and hopefully cure the disease, which is successful in the majority of patients.

There have been various studies to try to improve upon the efficacy of the transplant. Brentuximab vedotin, an antibody-drug conjugate has been approved as a post therapy treatment for a subset of these patients. And so this study was a multi-center phase 2 study to evaluate the safety and efficacy of brentuximab vedotin plus nivolumab, an immune checkpoint inhibitor in combination as a consolidation in high-risk patients with relapsed and refractory Hodgkin lymphoma.

So this study took patients that had received an autologous STEM cell transplant for relapsed Hodgkin lymphoma according to institutional standards at five centers, and then starting roughly one to two months after the STEM cell transplant, patients receive brentuximab vedotin and nivolumab every 21 days for a planned six cycles. This involved 59 patients. I won't get in to all the details. The net is that there were some toxicities as expected, including neuropathy from brentuximab vedotin and some autoimmune complications due to nivolumab. And again, these occurred leading to discontinuation in about 10 to 15% of patients, although a higher percentage of patients had less significant, but obviously meaningful toxicity.

And the net of this was thatat 18 months progression-free survival, meaning the number of patients who were still in remission was 95%, pretty good results, admittedly somewhat short followup at 18 months is reasonable. And the overall survival was 98%. And this was observed also in patients with two or three high risk factors.

And so I think why this got my attention was that this seems to be an interesting approach. It uses two new drugs, relatively new drugs. And then the group of patients that had a transplant that opted to go on this approach, obviously there are some selection issues here, but really only one of the patients on this study relapsed with, again, this relatively short follow-up. And I think we're going to see this combination studied in a variety of settings, not only after transplant, but earlier in the course of the disease as well. Nonetheless, I think there are these trials out there and I would encourage you to take a look at them, going forward because I think these are interesting results.

Number nine on the Leonard List for 2020 ASH is abstract number 534 entitled Clonal Somatic Mutations Are a Biomarker For Inferior Prognosis in Diffuse Large B-cell Lymphoma. This is led by Dr. Boddicker and colleagues at Mayo Clinic, including my colleague, Dr. Pinkal Desai here at Weill Cornell, who was a co-author on this.This time, they looked at patients with diffuse large B-cell lymphoma and looked at the issue of clonal somatic mutations. The idea that there are subpopulations of cells in patients predominantly as they age, many of these are in the normal non-patient or non-ill patient population. But the idea is that this clonal hematopoiesis as evidenced by these clonal mutations has been associated with a variety of different outcomes for various diseases and non-malignant diseases.

This study looked at diffuse, large B-cell lymphoma in particular. Two-hundred sixty one patients treated with immuno-chemotherapy. And the interesting thing here was that 17 patients or 6.5% had clonal somatic mutations. Sixteen of the 17 were over 60. So in older patients, this phenomenon seems to be more common, perhaps. And eight genes that were looked at included SF3B1, ASLX2 and TET2 were most frequent for clonal somatic mutations. And the bottom line is that the group of patients that had these clonal somatic mutations had a less favorable prognosis.

And so I think those are interesting data, like other malignancies, other diseases. Clonal somatic mutations are seen in a subpopulation of patients. And in this case, as in some other cases, it's been associated with a less favorable outcome. And so this obviously needs additional research, but I think this is an interesting and ultimately potentially relevant finding as a marker for outcome and potentially a marker for risk as well down the line, more work to do.

Next, we'll go to number eight on the Leonard List for ASH 2020. And this study that I've chosen for number eight is abstract 121, VLS-101, a ROR1-Targeting Antibody-Drug Conjugate Demonstrates a Predictable Safety Profile and Clinical Efficacy in Patients With Heavily Pretreated Mantle Cell Lymphoma and Diffuse Large B-cell Lymphoma. This is led by Michael Wang from MD Anderson and colleagues, including few of my colleagues at Weill Cornell.

ROR1, also known as receptor tyrosine kinase-like orphan receptor 1 is a protein that's expressed in embryogenesis and disappears by birth, but can be seen in transformed tissues, including in some hematologic and solid tumors. VLS-101 is an antibody drug-conjugate. It's an antibody against ROR1, conjugated with a linker to MMAE, which is an anti-microtubule cytotoxin.

And so this is the first in-human phase 1 study looking at usual parameters of this drug. It involved 32 patients, including mantle cell patients, 15 patients with mantle cell lymphoma. Toxicities include cytopenias and neuropathy. And interestingly, in the mantle cell subgroup of patients, seven of 15 patients responded. And in the five diffused large B-cell lymphoma patients, four of five responded to this therapy.

And so this is an interesting new treatment. It's an antibody-drug conjugate, may have applicability in diffuse large B-cell lymphoma and mantle cell lymphoma, and more studies are planned, but I think this is a drug that will be of interest in the future, One that has some potential in these difficult-to-treat lymphoma subtypes.

Now, for abstract act seven in the Leonard List ASH 2020 Countdown, we're going to move to, abstract number 373, Phase 1 Studies in Hematologic Malignancy, 20 Years Experience From Cancer Therapy Evaluation Program or CTEP at National Cancer Institute, National Institutes of Health. So this is your tax dollars at work. This is the federal government's data on phase 1 trials in blood cancers. CTEP is a major program or the National Cancer Institute that leads many of the clinical trials and oversees many of the clinical trials.

This abstract by Dr. Chihara and colleagues from that organization looked at a long experience. They looked at the database of investigator-initiated phase 1 oncology trials treated over about 20 years, 2000 to 2019, looking at toxicities, response and survival outcomes. There were just over 3,300 patients treated on 161 trials. And this is blood cancer trials, hematologic malignancies. There were about 1700 patients with leukemia or myelodysplastic syndrome, about 920 with lymphoma, and then a smaller number with other hematologic malignancies.

And so the take-home message of this is that toxicity over the various five-year periods was quite similar as far as the severe life-threatening toxicity. And, interestingly, the response rates were about 21%, 14% of patients had complete responses. And this was higher in lymphoma, over 40% of patients with lymphoma responded, lower in the other malignancies. And the overall survival, was on the order of nine months to these patients. And so the point being that over time, there's been an improvement in overall response response rate over the various time periods, overall response improved. The severe toxicity rate remained relatively low.

And again, many of these patients would appear based on the response rate and the durations to potentially have benefited from these studies. So I think I would agree with the authors that participation in phase 1 trials should be encouraged for some patients with hematologic malignancies, including lymphoma based on their overall situation, important take-home message for the clinical trial programs across the country, across the world in hematologic malignancies.

Next for countdown number six, abstract number six, we will move to the next abstract, which is abstract number 471 from Yasenchak and colleagues from Eugene, Oregon entitled Frontline Brentuximab Vedotin as ,Monotherapy or in Combination For Older Hodgkin Lymphoma Patients. The idea behind this abstract has looked at the issues of older patients, which is an increasingly, I think, recognized and targeted group of patients with Hodgkin lymphoma. The fact that this group of patients has a generally less favorable outcome in part because of their other medical conditions, in part because of their decreased ability to tolerate some of the standard therapies for Hodgkin lymphoma.

This looked at brentuximab vedotin, which we referenced earlier, the antibody-drug conjugate against C 30, that is used in a number of different Hodgkin lymphoma settings. And this phase 2 trial looked at different cohorts of patients. Some that received BV monotherapy by itself, some in combination with bendamustine, some in combination with dacarbazine and some in combination with nivolumab.

And the net of this study was that the different groups had different degrees of efficacy. The brentuximab vedotin plus bendamustine group had acute toxicities and closed early in this older patient population. But in fact, the groups in the other sets, whether it was monotherapy, where they had a duration of progression-free survival of about a year or the other combinations where it was certainly longer in the range of three to four years.

These patients seem to do reasonably well with this treatment, given their comorbid illnesses and other medical issues. And this certainly suggests that older patients can do reasonably well with brentuximab, particularly in combination with other agents or as a single agent, and that these combinations should be looked at further. And I think given the high toxicity observed with many older patients with Hodgkin lymphoma with standard therapy, particularly with bleomycin, these combinations warrant further evaluation and additional studies.

Now we're going to move to abstract five in the Leonard List Countdown for ASH 2020. And we will move to abstract number 208, Racial and Ethnic Disparities in the Survival of Patients with Indolent Non-Hodgkin Lymphoma in the United States: A Population-Based Analysis. This is an important analysis led by Dr. John Vaughn, who is a member of our team here at Weill Cornell Medicine.

And this study looked at the SEER or their surveillance, epidemiology and end results. Database looked at patients with indolent lymphoma, various subtypes. In this database, there were 63,000 plus patients with various lymphoma subtypes, mostly follicular lymphoma, but several other subtypes. But about 35,000 of these patients had follicular lymphoma. And it looked at outcomes by various demographic, racial and ethnic groups.

And the net of this analysis was that racial and ethnic minorities had a significantly increased hazard for excess mortality. This was after adjusting for age-sex, age-income histology. And so the net is that this group of patients had an inferior survival over the last two decades after adjusting for other variables. This was highest in American Indians and Alaska natives and was followed by non-Hispanic blacks, Asians, Pacific Islanders and Hispanics. And so the reasons behind this are obviously important and warrant further evaluation, and certainly suggests that efforts need to be targeted towards these subgroups of patients to try to understand and improve their outcomes with indolent lymphoma.

We'll now move to abstract four in the Leonard List Countdown for ASH 2020. And this is abstract number 117 led by Michael Wang and colleagues. And it's entitled LOXO-305, A Next Generation, Highly Selective, Non-Covalent BTK Inhibitor in Previously Treated Mantle Cell Lymphoma, Waldenström's Macroglobulinemia and Other Non-Hodgkin Lymphomas: Results From the Phase 1/2 BRUIN Study.

BTK inhibitors or Bruton tyrosine kinase inhibitors are very now widely used in various lymphoma subtypes, including mantle cell lymphoma and Waldenström's macroglobulinemia as well as marginal zone lymphoma. These are typically covalent inhibitors and there are pros and cons of covalent inhibitors that affect in particular the bioavalibilty and the half-life, which may lead to a different ability to cover the BTK target. And so LOXO-305 is a selective non-covalent BTK inhibitor. It inhibits both wild-type and C481-mutated BTK. This is one of the mutations that is associated with BTK inhibitor resistance.

And so this study looked at the efficacy of this agent as well as its safety. There were 186 patients treated on a number of different dose levels. Ninety-two had non-Hodgkin lymphoma. This particular abstract focused on the mantle cell group of patients in particular. In the 35 patients evaluable for efficacy with mantle cell lymphoma, the overall response rate was 51%, including nine patients of the 35 had complete responses and of note at the higher dose level or the recommended dose level, the response rate was 65%.

Again, a number of these patients had received prior CAR-T cell therapy, as well as BTK inhibitor treatment. And so, this is I think interesting data in particular with patients who have been through covalent BTK inhibitor treatment, and now benefited from this novel agent. And I think this agent will obviously be of interest not only in the relapse-refractory patient population, patients with disease resistant to BTK inhibitors, perhaps, as well as other settings. And so, again, an agent with potential out there to keep an eye on.

Abstract number three in our countdown is abstract 371 entitled Quality of Life After Diagnosis in Survivors of Aggressive Lymphoma. This is led by Robert Kraft and colleagues from the Mayo Clinic. This evaluated quality of life from patients newly diagnosed with lymphoma enrolled within nine months of diagnosis in the Molecular Epidemiology Resource or MER of the University of Iowa Mayo Clinic SPORE. This is really a great resource and it's contributed many findings at ASH year over year. I would say those of you who followed the Leonard List, they always have an appearance of one or two abstracts having great interest.

This study looked at quality of life at baseline, and then one, two, three, six, and nine years post-diagnosis in patients who have diffuse large B-cell lymphoma. And obviously with that followup, most of the patients were cured or did well and lived many years. So the interesting finding here is that the quality of life increased from baseline enrollment. And the largest increase was seen from baseline to one year after diagnosis.

So, you know, patients improve their quality of life despite getting lymphoma treatment over the course of their first year. Presumably part of that is due to the fact that their quality of life improves as their lymphoma goes away. And interesting, these continue to do well over time. And the bottom line is that quality of life in survivors of aggressive lymphoma is higher than the US general population at one, two, three, six, and nine years after diagnosis.

So fascinating and one can think about why that might be the case. And for me, it would be largely speculative. But I think it's interesting that quality of life can improve despite having a cancer diagnosis and receiving cancer therapy. And, you know, there are interesting ideas about how that experience might change one's life and the quality of life that stems from that. So interesting things to speculate about, debate about, and followup.

Next, number two on our list is coming up now, and that is the abstract number 306 by Hantel and colleagues from Dana-Farber Cancer Institute and Boston Children's Hospital entitled The Impact of Different Ethical Allocation Strategies on Survival During Vincristine Shortages.

And this really, I found of interest because as many of you know, and deal with, we have had some of our older chemotherapy drugs, like vincristine, vinblastine shortages at various point in times. And this has been really kind of, in some ways, hard to understand, and very difficult situation where you have some settings where we have the most curable diseases, childhood leukemia is one example, and we don't have the old, but effective drugs available for a variety of different reasons. And so we've been forced to modify how we use these drugs and, in some cases, cut back on how we use them or change the dosing or leave them out altogether if we don't have access to the drug or need to conserve.

And this study, which I won't claim to be able to explain, looked at couple of different models in the unfortunate situations where we find ourselves in a shortage how we might prioritize the use of vincristine based on different factors including first come first serve where you just treat whoever walks in the door first, prioritize on youngest age, efficacy per volume or worse alternatives. And the authors have gone through a number of different models to sort this out. And basically come up with amodel that essentially is focused on efficacy per volume and worse alternatives that can potentially have the best survival for the population as a whole in the unfortunate situation where we might have these models.

And so I think this is an interestingsort of way to think about these shortages. Hopefully, we will not have as many of them in the future. But at least this is one tool that one might consider to try to allocate things to benefit the largest number of patients where the greatest impact could be felt.

Finally, I'm going to give you number one before we get to our bonus. And number one actually comes from Min Xia and colleagues from Ari Melnick's Lab here at Weill Cornell Medicine. And I had to pick this abstract, A, because I think it's fascinating. I'm not involved in it directly. B, it comes out of our team from Weill Cornell and Ari Melnick who's being honored at ASH, is really one of the leading hematologic malignancy researchers out there. He's receiving a major award at ASH, you can keep an eye out for.

And this is just one more example of a great piece of work from his laboratory. He's had numerous plenary sessions over the years, which is quite impressive and great to collaborate with him. And this is also a plenary session. Applications as this audience like to know is the activated B-cell subtype of large cell lymphoma are among the most aggressive. DLBCLs, BCL10 gain-of-function mutations are seen primarily on the ABC DLBCLs. And these mutations cluster in the BN2 cluster 1 cases, part because they are likely transformed marginal zone lymphomas in many cases that are sensitive to ibrutinib treatment.

And so this is really elegant work that characterized BCL10 mutations in the CARD11 domain, and the MALT1 binding domain and in the C-terminal ST-rich domain relating to BCL10. And through a variety of different elegant experiments, the group evaluated the complex with CARD11 and MALT1 seen in these lymphomas.

And the net of this is that they understood features of the subset of large cell lymphoma that may go along with ibrutinib resistance and I won't get into the whole detail of this. And also that may potentially be targeted with a subset of these with a MALT1 inhibitor and MALT1 inhibitors are in clinical trials right now and have demonstrated really interesting properties. And so this is really, I think, a further potential precision medicine treatment strategy for a subset of diffuse large B-cell lymphoma. And I would encourage you to take a closer look at this and see the presentation because I think it's a very exciting work and work that I thought was really important to highlight as translational work with potential clinical implications in the future.

So thank you for joining us. And as a bonus for joining us, you get the five bonus quick abstracts, other ones that got my attention. I'll give you some just kind of brief highlights of these for the bonus five.

First, abstract 282 by Dr. Ubieto and colleagues entitled Minimal Residual Disease Monitoring from Liquid Biopsy by Next Gen Sequencing in Follicular Lymphoma Patients. This is the group from Madrid, Spain, looking at patients with follicular lymphoma and essentially looking at potential genetic markers by next gen sequencing to use for MRD or minimal residual disease analysis and tracking. the authors looked at a number of cases with follicular lymphoma, focusing in on cell-free DNA.

And the bottom line was thattechnique was used to identify mutation through cell-free DNA and positivity and negativity were determined and essentially showed that those patients that were MRD positive in the interim or end of treatment had a significantly inferior progression-free survival. And so this is really an interesting evolution andcontinued work in this field, a lot of work on both circulating tumor DNA and cell-free DNA as a marker of relapse. And this is one more study highlighting this, using a number of different MRD markers based on next gen sequencing. So, an interesting technique that has applications to a number of different lymphoma subtypes.

Next, I want to extend this discussion to Olszewski and colleagues from Brown university abstract 530, focusing on Cerebrospinal Fluid Analysis of Tumor-Specific Cell-Free DNA as a Diagnostic and Prognostic Tool for CNS Invasion and Lymphoma. The issue of identifying CNS involvement, identifying risk of CNS relapse in aggressive lymphoma patients is one that is quite complicated as is in some cases, diagnosis of CNS involvement, which can require invasive procedures to determine. And so this looked at a next gen sequencing MRD assay in the Cerebrospinal fluid, looked at a relatively small group of patients with either known involvement or other CSF samples from patients without involvement and then looked at high risk patients as well in other 19 patients to try to sort through the value of this in potentially identifying patients at risk for CNS involvement or CNS relapse.

And in the small proof of concept study, there was high sensitivity in diagnosing CNS involvement and I think using the cell-free DNA could be something that could be used in the future to potentially identify patients at risk for CNS involvement or CNS relapse who could benefit from additional therapy directed toward the CSF.

Along the same theme of cell-free DNA, or I should say circulating tumor DNA in this case, is abstract 531, Prognostic Value of Circulating Tumor DNA in Autologous STEM Cell Graft and Post-Transplant Plasma Samples Among Patients with Diffuse Large B-cell Lymphoma by Merryman and colleagues of Dana-Farber Cancer Institute. This looked at cohorts of patients undergoing autotransplant at Dana-Farber from 2003 to 2013, then they had the also later cohorts receiving a number of different maintenance or consolidation approaches through clinical trials.

And the net of this was that this looked at circulating tumor DNA in order to identify patient populations really before and after STEM cell transplant, looking at the sample before a transplant in particular. And the net of this analysis suggested that detection of circulating tumor DNA in a pre-auto STEM cell transplant plasma appears to be fairly predictive of relapse and in fact, potentially even better than a pre-auto transplant PET scan. And so the idea is that this may be a marker that can predict who needs additional intervention. So early study, but certainly an interesting concept, another potential use of,in this case, circulating tumor DNA.

Next one to move to, another abstract, which got my attention, changes gears a little bit. and this is abstract 311 Healthcare Utilization and End-of-Life Outcomes in Patients Receiving CAR-T Cell Therapy. And the concept here, this was by Johnson and colleagues from Mass General looked at patients retrospectively who received CAR-T cell therapy. Unfortunately, a subset of these patients do not do well because they have bad lymphoma, unfortunately. And unfortunately, some fraction of these patients die of their disease.

And this looked at the group of patients who received CAR-T cell therapy and died from their disease. Unfortunately in this group, the treatment was not successful. And the net is in the cohort of patients who did not do well, unfortunately, only about a third of patients were referred to hospice despite their poor outcome and less than half of them had received a palliative care consultation.

I think this is reflective of the fact that when you're giving patients CAR-T cells, depending on the situation, they may be in general are having a fairly aggressive approach to their care and all are hopeful for the effectiveness of the CAR-T cells. And I think this is a caution that unfortunately, some of these patients will not do so well. And I think it's incumbent upon us to also be mindful of the fact that they may need other supportive care, including palliative involvement in their care even if they're continuing to take an aggressive approach. And I think those of us working in this field need to keep this issue in mind. The whole issue of palliative care and patients with hematologic malignancies is one that's very important. And we do know thatthat is underutilized in many centers and situations. And I think we, as a community, need to at least keep that in mind in the appropriate setting.

And then finally our last kind of bonus abstract is abstract 706 byAlderuccio and colleagues from University of Miami entitled Prognostications, Survival and Treatment-Related Outcomes in HIV-Associated Burkitt Lymphoma: A US and UK Collaborative Analysis. The Burkitt lymphoma, these highly aggressive lymphomas have been associated certainly in some time periods with greater risk in patients with underlying HIV. And so this was a retrospective analysis looking at this group across 30 US sites and five UK centers treated from 2009 to 2018 looking at outcomes.

And the net is that there were 249 patients. So a large retrospective series, treated either with a CODOX-M/IVAC or Magrath regimen in 60% efficacious, dose-adjusted EPOCH in 25% and HyperCVAD based therapy in 13%. Most patients close to 90% have received rituximab. With median followup of 4.5 years, the three-year progression-free and overall survivals were roughly 60 to 65%, nearly identical in both countries and the Magrath regimen was associated with the highest three-year PFS of 66%, although it was quite similar with the other regimens. Dose-adjusted R-EPOCH a little bit lower at 51%. This was not statistically significant. And the CNS recurrence rate at three years across all the treatments was 10%, was higher with dose-adjusted R-EPOCH the other regimens.

And so, again, this is just a large analysis, retrospective analysis of HIV Burkitt lymphoma, gives us some hints about treatment, some hints about CNS relapse. But you know, also shows that the majority of patients were doing well three years later and certainly encouraged for the progress that seems to have been made in this group of patients that certainly in prior decades, did much less favorably.

So that brings us to the close of this discussion. I really want to thank you for joining us today. And thanks for tuning in and listening to this year's 2020 Leonard Lists from the American Society of Hematology top 10 plus five bonus abstracts focused on lymphoma and related malignancies.

Hope you agree with some of these, hope you're disagree with some of these, have other ideas. Feel free to reach out on Twitter or otherwise and think about your own interesting abstracts as well that you find important for the community to know about. It's great to have these meetings and venues to talk about the progress and lots of reasons for our patients and their loved ones and all of us in the community to be excited about the progress in blood cancers in general and lymphoma in specific.

I also want to encourage you to download, subscribe, rate and review CancerCast on Apple podcasts, Google Play Music or online at WeillCornell.org. We have lots of other episodes as well that you can find in the same places. And we hope you'll tune in and take a look at them,some great topics in the past episodes and we have a lot more in store in the future. You can also write to us at cancercast@med.cornell.edu with questions, comments, and topics you'd like us to cover more in depth in the future.

That's it for CancerCast, conversations about new developments in medicine, cancer care and research. I'm Dr. John Leonard. Thanks for tuning in.