Transcription:
What to Know About Cervical & Other Gynecologic Cancers

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 on the podcast, we'll be talking about women's gynecological cancers, including cervical cancer, ovarian cancer, and other less common cancers that can occur in this part of the body. 

Our guest for this episode is Dr. Eloise Chapman-Davis, a gynecologic oncologist and the Division Director of Gynecologic Oncology at Weill Cornell Medicine and New York Presbyterian Hospital. Dr. Chapman is an expert in caring for patients with cervical, ovarian, vaginal, vulvar and uterine cancers. In addition to providing medical management for patients with these cancers, Dr. Chapman performs minimally invasive surgeries and conducts clinical and translational research studies in order to move the field forward and address healthcare disparities.
Today, we're really looking forward to an in-depth discussion about what people should know about these women's cancers ranging from prevention to screening and treatment. So Dr. Chapman, thanks for being here and helping us to increase awareness in this area of women's health, which is very important. Thanks for joining us. 

Dr Eloise Chapman: Thank you so much, Dr. Leonard, for having me on for this very important conversation as it relates to women's health. 

Dr John Leonard: So I wanted to start by asking you how you ended up working in this area specifically. What led you to gynecologic oncology in particular amongst all the fields of medicine?

Dr Eloise Chapman: Well, I must admit as a medical student what drew me into medicine in general was surgery. And I was really interested in anatomy and how the body worked. And what I found that was interesting between surgery and also pathology and disease itself, I realized that surgery is sort of one aspect of care. But, what really is important is understanding what do you do after you do a surgery or cut something out. When I did my rotations, it was very clear that I really cared about continuity of care and trying to understand the long-term relationships and consequences of disease and what things can we do to not just treat the person in the moment, but to treat the whole person and to continue to take care of them well beyond their diagnosis. I found that when I met cancer patients, specifically gynecologic cancer patients, that these women were of all ages from young women to older women. And, obviously, as in any cancer diagnosis, it affects them, but it affects them, their family, their fertility, a lot of other issues come into play. And they also were some of the best people that I would meet as patients and felt that caring for these patients was something that was a privilege. And I was able to not only be a part of their surgical care, but I also will give chemotherapy and monitor these patients and sort of become like their new primary care doctor for their cancer care through their diagnosis, surgery, chemotherapy treatments and also their survivorship. And so this is a kind of a unique field that encompasses so many aspects of medicine that's important and in a high risk group of women where it's critical to have people who really understand their needs.

Dr John Leonard: I think as a medical oncologist and hematologist, it's a very interesting perspective that you just mentioned and something that I've recognized that GYN oncologists, and in particular, the great team that you lead here, does both surgery and medical treatments and provides that comprehensive care, which is different than many other sub-specialists.
I mean, most medical oncologists see the patient, either before or after their surgery, but, there's kind of a handoff in many situations. But in GYN oncology, and in your team, you cover the waterfront, which must be very rewarding and a different perspective.

Dr Eloise Chapman: It is. And just on a personal note, what drew me to cancer care in general is that, as a minority first-generation immigrant in this country, a lot of my family members unfortunately have died from various cancers. And what I found is that not everyone understood how to navigate the system and what to do. And for me, it really hit me personally. As a resident because my father got diagnosed with metastatic gastric cancer, and unfortunately passed away before he could see me finish my role to be a GYN oncologist. And it was very clear to me during his treatment and what he went through, that I was really passionate in being able to be a provider for cancer care in a way that I would want my family member to be provided for. 

Dr John Leonard: Oh, thanks for sharing that. And I know, working and, addressing disparities is a big part of your work. So we'll definitely come back to that, as we continue our discussion Weill Cornell has a strong history in gynecologic cancers. The pap smear was developed here. Dr. George Papanikolaou was here and, really, there probably are a few interventions over the decades that have made such an impact in cancer in general, not just GYN cancers. 

Dr Eloise Chapman: I would agree. Dr. Papanikolaou's discovery essentially changed screening for cervical cancer in a way that a lot of cancers may take years to be able to find something that can help prevent a cancer just through screening and this has now helped to shape how we protect women from developing cervical cancer in the future. 

Dr John Leonard: Why don't we go into an overview of different and most common gynecological cancers. We alluded to earlier, the fact that you, treat women with a variety of different, tumors, of this part of the body. We're presenting this, in January, in recognition of, cervical cancer awareness month, but there are obviously many other important cancers, that women need to be aware of and are dealing with. So we have cervical cancer, cancers of the ovary, the uterus, the vagina, the vulva. What are the most common cancers in women, in this area of the body? And which are the ones that are the most important from the population perspective? 

Dr Eloise Chapman: When I think about gynecologic cancers, the first thing I'd like to highlight is that, in women, we have different reproductive organs. And as in anything, those are still considered solid areas that can turn into a cancer or pre-cancer. And I’ll start with the uterus because that is the most common cancer. Period. Among all of the female reproductive organ cancers. And these uterine cancers can arise from the lining of the uterus, what they call endometrial cancer. They can sometimes arise from the muscle of the wall of the uterus, which can become things called sarcomas. but the most common types of cancers tend to be uterine or endometrial type of cancers.
And the reason why I bring that up is because this is one cancer that is the most curable. And also has the most modifiable risk factors as the usual causes associated with uterine cancer is due to increase exposure to estrogen. Now, these increased exposure to estrogen, the most common reason for it is obesity. And, obesity is an epidemic in of itself, but it's definitely related to an increased risk of developing uterine cancer. And then also common medical problems such as diabetes and hypertension can cause a twofold increase in a woman's risk for developing uterine cancer. And so, these are some of the things that are very important to know.
Uterine cancer, as the one cancer that there's a symptom, which is either irregular uterine bleeding or bleeding in a woman who was supposed to be post-menopausal. When I think about the types of cancers, this cancer not only is the most common, is associated with multiple modifiable risk factors, but also has a symptom. And so with that being said, if you have these symptoms, you have a chance to tell your physician and be able to get a diagnosis early on, which also makes it the most curable because it tends to be found in early stages.
Now, cervical cancer is the fourth most common cancer in the world. In other less developed countries, cervical cancer ranks like the first or second cause of cancer. In the United States, it's still considered a higher rate of cervical cancer compared to some of the other more rare cancers, such as vaginal or vulvar. It's still one of the most preventable because there's a screening test, there's a pap smear and then there's also a vaccine for it. And so this is another cancer that has not only a precancerous phase before it develops into a cancer, but you have both prevention strategies in terms of vaccination as well as Pap smear screening and HPV testing, which have both been proven to really decrease the risk. Part of the biggest problems we have right now with combating cervical cancer relates to access to care and the lack of HPV vaccination in this country. In other developed countries, they use it a lot and they've seen significant decrease in cervical cancer rates.
The next cancer that we take care of is ovarian cancer patients. And, again, although it's the less common cancer, about one in 70 women will develop ovarian cancer compared to something like breast, which is much more common, like one in seven. What we know about ovarian cancer, why it's so scary is that it's still the fifth leading cause of death among women. And so, although it's not as common for women to get ovarian cancer, it has a much higher mortality. And so what that means is that the reason why this tends to happen is because the symptoms that you have with ovarian cancer may not be so clear cut. It's not like uterine cancer when you have bleeding. And that may trigger you to say something about it. a lot of the symptoms are very unclear and things that can happen like bloating and, problems with what you're eating or things that you may think are just common things that can happen. GI complaints, or gastrointestinal complaints things could just be something you ate that was bad. And so, unfortunately by the time most women are diagnosed with ovarian cancer. It usually is pretty advanced stage. And what that means is that it's a point in time where the prognosis is not as great and you ultimately will need chemotherapy then other major treatments to even get some benefit in terms of life expectancy. Now in terms of vaginal and vulvar cancers, which I left for last, these are very, very rare cancers. The things that we need to know about vaginal and vulvar cancers, although they're rare, they're really associated with women who are smokers, is associated with HPV or human papilloma virus, which I think we'll talk a little bit about later and also with just chronic, irritation in the area of the vulva.

And that can come in forms of things like lichen sclerosis, which if you think about it is sort of thought of like an eczema or a white plaque down there, something that causes itching and burning on the outside. And we see that in a lot of post-menopausal women who may just ignore those symptoms, but that's why it's very important to have a gynecologic exam because a lot of these can be prevented. If someone notices something on the vulva, usually the gynecologist who will biopsy it. And then again, we'll allow for early detection and treatment at early stages. 

Dr John Leonard: For a woman who does not have any particular risk factors for gynecologic cancer, what is the typical screening regimen that's recommended for most women? Is it a yearly exam with a Pap smear? What else is done? And does that continue throughout one's life? 

Dr Eloise Chapman: Well, I think that's a little bit of harder question to answer. The reason why is because the recommendations are a little broad based on age, especially as it relates to the pap smear screening. And so I would say this, I definitely recommend in an annual visit with, either a gynecologist's, a primary care physician who actually will do gynecologic exams, family medicine practitioners, because I think this idea that once I am finished having children, I no longer need to see a gynecologist is sort of the biggest mistake in terms of preventing detection. Because again, just having a gynecologic exam by someone who is looking in that area, doing usually a speculum exam to look in the vagina, doing a pap smear when it's warranted and a pap smear these days, the recommendations vary across age. But the key thing we have learned is that HPV or human papilloma virus testing, now that we have that DNA testing that has been proven to be even more sensitive than a pap smear and detecting your risk for cervical cancer over a five-year period. So even if you saw a doctor and they just did an HPV test outside of a pap smear, it checks for specific high-risk HPV. subtypes that are linked to approximately 80 to 90% of the types of cervical cancer. So if you do not have these high-risk HPV subtypes, usually they look at something called HPV 16, HPV 18, and HPV 45. Your chances that you will develop cervical cancer within five years is highly unlikely. So just having that test done alone really should provide women with some fault of security that they're not missing a diagnosis of cervical cancer. But again, to get that test done, you really have to be seen by a gynecologist to be able to evaluate for that. In terms of other screenings, we've looked at screening for ovarian cancer, but unfortunately there has been nothing proven for early detection. Now, the idea of needing an annual ultrasound has been debunked and very large screening trials have not shown any increase in detecting ovarian cancer earlier or improving the survival in women who end up ultimately getting ovarian cancer. But if you have a family history of any of these cancers, that is also something very important to discuss with your doctor. And so when we mean family history, what we do know about some of these gynecologic cancers is that both breast cancer, as well as ovarian cancers can be associated in families and can be linked together as a risk factor for hereditary syndrome. And what I mean by hereditary syndromes are things that can be passed from generation to generation. And in those patients, if you get early detection based off a genetic screening to rule out these specific mutations, if you are found early enough to have them, then it does change your screening pattern, and that can definitely help to prevent you from developing these cancers, including increasing your options for prophylactic surgery.
Some of the other cancers that can be associated with uterine cancers and syndromes are colon cancer. So, I mean, I think the biggest thing is to know your family history of cancer, and if you're doctor does not ask you about it, you should tell them about it. Because if you have certain risk factors, you should absolutely request to be referred to a genetic counselor who can help stratify your risk and also help to determine if you need genetic testing. Learning about your genetic history could essentially save your life and the future and your children's lives. And it also will help with determining if you qualify for additional screening. 

Dr John Leonard: So it sounds like in general, the key for the genetic screening portion of things is really your family history. 

Dr Eloise Chapman: Correct. And I know that, most doctors are very busy. You want to get down to asking things about your own medical history and medications and such, but it's important to make sure, you know, your family history. Ask your family about it. And sometimes you may not know the details of it, but you'd be surprised what you can learn, but you at least have to let your doctors be aware of your concern, if you do have any family history of these types of cancers. 

Dr John Leonard: So I'd like to get into the cervical cancer issues a little bit more. You alluded to the different subtypes of human papilloma virus or HPV that can be associated with less of a risk, either a certain subtype or I presume no subtype. Can you comment again on the types that have a higher risk of cervical cancer? 

Dr Eloise Chapman: Some of the things that we have to understand that a part of the screening recommendations of how often we test women that vary by age in general, they don't recommend to do any HPV testing until 30. Women who are 25 and younger have much higher risks to being exposed to HPV in general.
So the human papilloma virus is a virus that is transmitted from skin to skin contact, usually through sexual contact, and we know that in younger people, the way you clear a virus, just like any virus your natural immunity will help to clear the virus. And so typically about 50 to 80% of women in their lifetime will be exposed to some type of HPV. But we're not walking around with 80% of women with cervical cancer. So what that means is that the majority of women will clear it on their own. And they usually clear it within one to two years, about 80% of patients. But unfortunately about 20% of patients, depending on their HPV subtype may go on to have more higher grade precancer lesions and then ultimately cancers. So what we do now with HPV testing is that we typically co-test, meaning that we test for HPV at the same time as you do a pap smear. And the goal for doing that is the way to be able to risk stratify, which women we need to follow more closely, and which women are more likely to go away. And so when we think about HPV, the subtypes that we look at, like six and 11 are usually associated with things like genital warts. They're low grade, they go away on their own. We don't really care about that. The HPV 16, 18 and 45 are sort of the main subtypes that we care about that are considered more high risk. And specifically 16 and 18 are associated with 80% of development to cervical cancer. So when I say that, it doesn't mean that 80% of women who have 16 to 18 will develop cervical cancer. It means among the women who have cervical cancer. They detected people who've had 16, 18 around for a very long time. And so because we know that when we look at what we call genome subtyping, what we do at the time of a pap smear is we check for HPV status and either the HPV is positive or negative. If it's positive for high-risk HPV, it subsequently goes through what we call genotyping. And that genotyping looks at. 30 different types of high-risk HPV, but understanding that 16, 18 and 45 are the ones that we're most concerned about. So just because you may have a positive high-risk HPV first screen.
The second screen, which is a genotype is looking specifically at 16, 18 and 45. And so the reason why that's important is that when a woman now goes to get a pap test and HPV testing, there may be three results that you get back. You can get a pap smear that could be normal. You can then have a high-risk HPV test that's positive, but then you can have a 16, 18 HPV test that's negative. And that's not a bad thing. All you do is repeat in a year. If there's something that is showing things that are more high grade, meaning that you have a high-grade pre-cancerous pap smear in conjunction with positive high-risk HPV, then you may have to be triaged right away to do more screening where they're looking at your cervix more closely. Doing something called a colposcopy and biopsies, which I would recommend because that is how we help to prevent cervical cancer, because if we find something to treat, we can get rid of it very easily with small procedures so that it never develops into a cervical cancer. 

Dr John Leonard: I think many people are aware of the importance of the HPV vaccine. How does the vaccine change this whole picture and, pretty much should everybody get an HPV vaccine that, falls into the recommended age guideline? 

Dr Eloise Chapman: It's a great question. And what we have learned, because of the HPV vaccine, which by the way was initially FDA approved since 2006. We’ve had more than 1.8 million women in the world who have gotten vaccines done. And so we have a lot of data to show about the proven efficacy of the vaccine. I think the misnomer about this vaccine is that the goal of the HPV vaccine is to have people build very high antibodies so that they never get HPV infection, which then is what leads to the cervical pre-cancer and then cervical cancer. And so the goal of this is not to give the vaccine. Once you already have HPV, you sort of missed the boat a little bit. The efficacy is not good as a preventive strategy. The goal is to give the vaccine before you've ever been exposed. And so what we have done in this country, which we have not done that great as far as looking at rates in the world. We probably only have a vaccination rate of about 40%, which is very low. Whereas if you look at places like Australia and Sweden, they have 90, 95% because they pushed the HPV vaccination programs where they should be, which is in children. And so the recommendation right now, the vaccine is approved was from ages nine to 26 and now has gone up to age 45. The reason why we push to get vaccines done in our 11 to 12 year old boys and girls is the goal is to get the vaccine done before they have any exposure to the HPV, which would be potentially before any sexual interaction and that's for boys and girls. And so where I want to push people and me meaning that our patients for their children, this is how we help to get rid of cervical cancer in general is to get a pretty large herd immunity of people who are vaccinated so that they never get the actual infection. And they've looked at this in large studies where they show that. If you give the vaccine in the 11 to 12 year olds, they've had over a 90 to 95% reduction in cervical cancer incidents, and they show them these enlarge trials in countries that actually vaccinate. So, this was a pretty large trial in Sweden and in Australia. And this was a really big deal where they showed that in a large study with millions of women and girls who've been vaccinated that the younger, they got it, that they confirmed down the line looking at many years later, if they were vaccinated before the age of 17, that they showed a 90% reduction in cervical cancer incidents. And this was over a 12-year study period, and this was very high compared to the rates of people who were un-vaccinated during that same time period. And so if we look at what has been done in other countries. And the United States, if we could move to our more increased HPV vaccination program, we would be really showing a decrease incidence in cervical cancer, which in the United States has kind of remained more flat.
We have shown some improvement over the last 10 years from vaccinating adolescents compared to the previous years where people were not getting vaccinated until they were in their twenties. And by then the efficacy rates of like a hundred percent of no infection goes down substantially because a lot of those women already have been exposed to HPV. Now I say that we shouldn't just say don't vaccinate if you've already had sex, I still recommend it. And it's recommended up to age 45. But as a woman who treats a lot of young women who develop these pre-cancers and certain cancers and reproductive age, where they may lose their chance or fertility, they all come and tell me, I wish my parents vaccinated me. Like I don't understand. 33-year-olds pregnant having to lose their child and do these major surgeries and radiation and chemotherapy very young, just because they never got vaccinated or had persistent HPV that was never treated. And these are things that are completely preventable.

Dr John Leonard: Briefly then the reason that older women don't get vaccinated or are not recommended to be vaccinated is that basically they've already had their exposure and therefore the benefit of the vaccine would be less. Is that correct?

Dr Eloise Chapman: Well, and not even just that, because as any vaccine, this specific vaccine, because it's vaccinating against the virus is your ability to amount and appropriate immune response. So we know from multiple vaccine studies that have been done, when you're young, you have the highest rates of mounting a huge response. By the time you're older, those response are not long lasting.

And just, the benefit is not been shown to be there because they've missed the window. And between exposure risks, they've already had long exposures, and the inability to mount affective responses. They've shown that the benefit is just not there to give to older women for vaccination.

Dr John Leonard: At a high level, what are the main treatments for cervical cancer? You mentioned colposcopy and I'm sure there are some local approaches for women with very early stage disease or early lesions. What's the range of approaches for women in different categories? 

Dr Eloise Chapman: When we talk about cervical cancer, the biggest difference as compared to other cancers is that we really want to push to find it early. And so when we mean early for cervical cancer, we mean having a tumor that's less than two centimeters on the cervix and has not spread any place else. And so that's sort of considered like a stage one type of cancer. Unfortunately, once the cancer has spread anywhere, even just to the outside of the cervix or uterus or other places, it's like stage two and above surgery is off the table. So on a high level, when you are found early, the earlier you find it a) you have an opportunity to potentially spare doing a major surgery, meaning removing your cervix and your uterus and other potential other biopsies that need to be done that can make a young woman lose their ability for fertility. You find out very early, you can sometimes just do something called a cold knife comb, where you just resect the abnormal portion of the cervix, but still are able to have people maintain their fertility. Once you get higher up in our staging, even within a stage one, the only treatment is to remove all of the gynecological parts, as well as the lymph node biopsies, with the hope for cure. Once you get into stage two and above the locally advanced disease, the treatment typically is a combination of chemo with concurrent radiation, sort of low dose chemo with radiation. And then after going through all of that treatment, we hope for cure. And once you get pretty far, like it's spread outside of the uterus, cervix, or pelvis to other parts of your body, the treatment is then just chemotherapy. And as we move up the ranks from any stage or how far it's spread, obviously the prognosis gets lower and lower. 

Dr John Leonard: It sounds like a key aspect of this is a multidisciplinary team because some of what you describe really can involve radiation, can involve chemotherapy at other settings. I'm sure there are fertility specialists that might be involved in the care of some patients. 

Dr Eloise Chapman: I would say, good thing about working in a place like this is that as with any cancer diagnosis, new cancer diagnosis, we meet as collectively as a group, as a tumor board group – what we call it – where we review the diagnosis with our radiation colleagues, our radiologist, our fellow gynecological oncologists again, because we also give chemotherapy and we review all of the imaging. Come up with a multidisciplinary plan. And of course we also have our pathology colleagues as well. And for young women specifically, we have an excellent reproduction endocrine infertility team that specifically work with patients who have new diagnosis of cancer, where we've been able to freeze eggs, get things done within a week and a half of their diagnosis so that we don't delay the treatments that they need. And on the other hand, cervical cancer, unfortunately, because it can happen in younger women, one of the cancers that are actually commonly found once a woman is pregnant. And so I myself have taken care of pregnant women who also have a diagnosis of cervical cancer at the time of pregnancy.
And because we have a world-class obstetrics department, high-risk MSN team, I'm currently taking care of patients. I've taken care of patients who are pregnant, that we've been able to get them through their pregnancy, deliver their baby, and then go right into treatment that they need immediately, right after delivery. So these are all things that, you need to be in a center that have access to all of these things so that we can make it happen very quickly and efficiently. 

Dr John Leonard: I wanted to finish up by getting a sense for the audience of your research interests, also your thoughts on how the challenges of disparities in cancer care and screening particularly impacts this area. 

Dr Eloise Chapman: I think for me, understanding that here we have a cancer such as cervical cancer, that can be prevented by a vaccine a) and also by understanding your risk factors. I think the key thing, and when I look at some of my research aspects that I look at in reducing disparities is a) pushing prevention strategies, and also pushing people to understand women, to understand early detection and their health. And so some of the things that I'm working on right now has to do with patient education around the human papilloma virus as one aspect. And that patient education goes to what happens if I get an abnormal pap smear, things like I alluded to, as far as colposcopy, these are procedures that can be done that are preventative, that will ever prevent a woman from getting cervical cancer. But as a woman, who's taking care of a lot of women of various ages. The misinformation is so large around cervical cancer. And so part of the study that I've worked on is I've helped to create some more patient friendly information through something called the PALS or Patient Activated Learning System, which is something that was actually invented here through Weill Cornell medicine, in conjunction with Dr. Monica Safford. That focus on trying to improve healthcare literacy around various diagnoses. And as my focus is on cancer diagnosis, I helped to create a series of videos, centered around both HPV vaccination. One part of the studies is to gear towards parents, within the pediatric department to focus on the 11 to 12 year old parents, to let them understand, why this is important to also to dismiss a lot of the misinformation around the vaccine. With the hopes to follow, if this helps to impact an increase rate of vaccination in both the pediatric 11 to 12 and adolescent clinics that we have here, you have to get to the parents to get to the children. And then we also have sort of this catch-up vaccination part of our research, where we're looking to make sure that when with girls once they get 18 and they can make their own decisions, understand the importance of still trying to get vaccinated, even if they already have some early exposures. And second piece of the information I'm working on is really to help patients with follow-up after an abnormal pap smear. We know from data that that is a big risk factor for developing cervical cancer, that women will have a pap smear and not follow up. They didn't know it was important. They didn't know exactly why they needed to do the follow-up or what it entails. And so we are catching a lot of women who already have a diagnosis to make sure that we are navigating them to get their proper follow-up and biopsies again, using this health literacy platform that we have called the PALS program, where we have created it to be able to mobilize via text messaging and emails. So that it can be directly to the patient and to leave the provider out of it. Because we realized that everyone are great communicators, but I think if we can go directly to the patient in a way that is easy for them, whether it's through an app, text messaging systems and to make them accountable for follow-up through education and making sure they meet their appointments, that this hopefully will have a long-term effect to help to reduce some of these disparities. That's just a little bit of what I'm doing but I just wanted to put out the main things that we really are focusing on is trying to get to people before they already have their diagnosis. 

Dr John Leonard: It strikes me that that this is really an area where a patient or a patient's friends and loved ones and community can have the most direct impact. I mean, the idea that you can get screened and have a vaccine where you can prevent a cancer. It's not requiring someone to change their diet for years or something else, simply get a vaccine. You can make a huge difference. So it seems like understanding and addressing these issues really, is a huge way to have a major impact.

Dr Eloise Chapman: And I can tell you just from the patient experiences, they always say, once they've already got diagnosed with cancer, that they are huge proponents. I will vaccinate my kids. I don't ever want my children to go through this. But again, I think it's just getting that information out there and having women understand how best to protect their own health. 

Dr John Leonard: Well, thank you so much for taking the time to give us an overview primarily on cervical cancer. But we touched on, a number of other gynecologic cancers, and we'll have you come back and get into the details of these in the future. So, thanks for taking the time today. It's been a great discussion. I'd like to invite the audience to download subscribe, rate, and review CancerCast on Apple podcasts, Google podcasts, Spotify or online at weillcornell.org. We also encourage you to write to us cancercast@med.cornell.edu with questions, comments, and topics. You'd like to see us cover more in depth. That's it for CancerCast conversations about new developments in medicine, cancer care and research. I'm Dr. John Leonard. Thanks for tuning in. 

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