Latest / Becker’s Healthcare Podcast / Jodi Skiles, MD, Medical Director of the Pediatric Stem Cell Transplant Program at Riley Hospital for Children

Transcript

Jodi Skiles, MD, Medical Director of the Pediatric Stem Cell Transplant Program at Riley Hospital for Children · Becker’s Healthcare Podcast

• 0:02
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  - upper right.
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  - Hello. Thank you so much for tuning in
• 0:54
  - to the Becker's Oncology Leadership Podcast.
• 0:57
  - I'm Elizabeth Gregersen, a reporter here at Becker's.
• 1:00
  - And today, I'm talking to Jody Skiles,
• 1:03
  - doctor Jody Skiles,
• 1:05
  - medical director of the pediatric stem cell transplant
• 1:08
  - program at Riley Hospital for Children in Indianapolis
• 1:12
  - and the FACT Accreditation medical director for both
• 1:15
  - pediatric and adult stem cell transplant programs at
• 1:18
  - Indiana University.
• 1:19
  - Doctor Skiles, thank you so much for taking
• 1:21
  - the time to speak with me today.
• 1:23
  - Of course. Thank you for the opportunity to
• 1:25
  - be here.
• 1:26
  - Absolutely. And before we dive into our conversation,
• 1:28
  - because it's a good one for our listeners,
• 1:30
  - I would love if you could share just
• 1:32
  - a bit about your background and your role
• 1:34
  - at Riley Hospital for Children.
• 1:36
  - Sure.
• 1:37
  - So I have been on staff at Riley
• 1:41
  - since 2012 when I graduated from fellowship. So
• 1:44
  - my background training, I was internal medicine and
• 1:47
  - pediatrics trained
• 1:49
  - for residency,
• 1:50
  - at Indiana University,
• 1:52
  - and then I stayed on for pediatric hematology
• 1:55
  - oncology fellowship just on the pediatric side for
• 1:58
  - oncology.
• 1:59
  - And then I became a stem cell transplant
• 2:01
  - physician, and I have been here since 2012.
• 2:04
  - And I've been the medical director of the
• 2:05
  - pediatric program since 2018 and the FACT accreditation
• 2:08
  - director since 2023.
• 2:11
  - Perfect.
• 2:12
  - And I'm excited to share the reason that
• 2:14
  - you're on the podcast today.
• 2:16
  - In February of this year,
• 2:18
  - a 14 year old patient at Riley Hospital
• 2:21
  - for Children became the first
• 2:24
  - pediatric patient in the world to receive a
• 2:26
  - bone marrow stem cell transplant
• 2:29
  - using cells from a deceased
• 2:31
  - donor.
• 2:33
  - Doctor Styles, can you walk
• 2:35
  - our audience through what made this case different
• 2:37
  - and why this approach matters
• 2:40
  - for the industry.
• 2:43
  - Sure. It really is very exciting.
• 2:47
  - So
• 2:47
  - our patient is a 14 year old who
• 2:50
  - was originally diagnosed with acute myeloid leukemia in
• 2:53
  - the fall of twenty twenty five, And
• 2:56
  - he received his upfront chemotherapy,
• 2:58
  - but, unfortunately, was
• 3:00
  - refractory to chemotherapy. His disease did not get
• 3:03
  - into remission as quickly as what we expected,
• 3:05
  - and that made him eligible to receive a
• 3:07
  - stem cell transplant.
• 3:09
  - So we proceeded to his stem cell transplant
• 3:12
  - according to sort of standard of care.
• 3:15
  - We
• 3:16
  - found an unrelated donor through the NMDP
• 3:20
  - and received those donor cells, and his original
• 3:23
  - transplant,
• 3:25
  - his first transplant
• 3:26
  - happened in
• 3:28
  - late December, early January.
• 3:30
  - Unfortunately, that donor cells did not grow.
• 3:34
  - His
• 3:35
  - the patient's immune system rejected those stem cells
• 3:38
  - from coming in,
• 3:39
  - And so that forced us into a situation
• 3:41
  - where we had to be
• 3:44
  - very nimble in trying to find a new
• 3:46
  - donor for him. And, really, when you're in
• 3:48
  - that situation,
• 3:49
  - it really is life and death scenario where
• 3:53
  - if a patient's stem cells fail to engraft
• 3:55
  - with a transplant,
• 3:56
  - you really need new cells in very quickly
• 3:59
  - in order to not allow that patient to
• 4:01
  - succumb to infections.
• 4:04
  - Primarily viral infections, can really become a big
• 4:06
  - problem when you don't have an immune system.
• 4:08
  - And so we were in a situation where
• 4:10
  - we were looking for a backup donor and
• 4:12
  - looking to move very quickly.
• 4:15
  - Because we know that this is something that
• 4:16
  - can happen in transplant, we always enter into
• 4:19
  - a stem cell transplant
• 4:20
  - with a plan a and at least a
• 4:22
  - plan b, hopefully, also a plan c and
• 4:24
  - d.
• 4:25
  - And in this patient situation,
• 4:28
  - his plan b that we went to mobilize
• 4:30
  - and activate, that plan fell through.
• 4:33
  - For a variety of reasons, that that plan
• 4:36
  - did not work out.
• 4:37
  - And, unfortunately,
• 4:38
  - this patient did not have a plan c
• 4:40
  - or d. And so we found ourselves in
• 4:43
  - a situation where we were reaching out to
• 4:44
  - NMDP to say, can you please help us
• 4:46
  - mobilize a replacement donor very quickly?
• 4:49
  - And they were very willing, but the best
• 4:51
  - that they could do was, like, a four
• 4:53
  - to six week timeline
• 4:54
  - in order to get a backup donor mobilized.
• 4:58
  - And we knew that if we waited for
• 5:00
  - that timeline to happen, that our patient would
• 5:02
  - not survive.
• 5:03
  - And so we had to put on our
• 5:05
  - thinking caps and become innovative, and we were
• 5:08
  - aware of a company called Osteom,
• 5:11
  - that they had been working to bring forward
• 5:14
  - the option for deceased donor stem cell transplants,
• 5:18
  - through a clinical trial process.
• 5:20
  - And
• 5:21
  - we had been in conversation with them about
• 5:23
  - potentially opening that trial, but we had not
• 5:25
  - activated things for that trial yet. And so
• 5:28
  - I reached out to Osteem and asked, hey.
• 5:30
  - We have an urgent need. We have a
• 5:32
  - patient's life on the line. Can you help
• 5:34
  - us? And they were very gracious in saying,
• 5:37
  - yes. We absolutely can.
• 5:39
  - Let's get to work. And so from the
• 5:41
  - time that I reached out to them until
• 5:43
  - the time that we had cells available for
• 5:45
  - this patient, it was about a week,
• 5:47
  - to get through the process. And, and being
• 5:50
  - totally transparent, it was a crazy week. It
• 5:52
  - was lots of work.
• 5:54
  - I would not
• 5:55
  - advocate for doing, a deceased donor transplant under
• 5:58
  - that kind of stress and pressure.
• 6:00
  - Being proactive is always better, but, we were
• 6:03
  - able to get it done with a lot
• 6:05
  - of support from Oceum.
• 6:06
  - And,
• 6:08
  - and as a result, the patient survived and
• 6:10
  - is doing great.
• 6:12
  - Amazing. Thank you for,
• 6:14
  - kind of
• 6:16
  - giving us the overview, I know, as
• 6:18
  - comprehensively as you can.
• 6:21
  - I remember when the news broke.
• 6:24
  - It says four thousand children a year in
• 6:26
  - The US are diagnosed with blood cancers that
• 6:29
  - may need a transplant.
• 6:31
  - And the process you just mentioned obviously highlights
• 6:34
  - how finding a living living donor is still
• 6:37
  - one of the biggest bottlenecks, and like you
• 6:39
  - said, is a life or death situation
• 6:42
  - without the four to six weeks that you
• 6:44
  - can wait. Right?
• 6:46
  - How big of a dent do you think
• 6:49
  - deceased donor stem cell banking can realistically
• 6:53
  - make
• 6:54
  - in
• 6:55
  - this gap over the next five years? And,
• 6:58
  - you know, what would need to be true
• 7:01
  - for this type of process to scale beyond
• 7:03
  - just kind of a small number
• 7:05
  - of transplant centers or unique patients where it
• 7:08
  - just works out, just like you said, after
• 7:10
  - a crazy week.
• 7:11
  - What does that look like?
• 7:14
  - Yeah. I think it's a really good question.
• 7:16
  - And I think the the important
• 7:18
  - point is that, it's not
• 7:21
  - this this type of donor is not just
• 7:23
  - for children. It's also for adults.
• 7:25
  - Our patient was the first pediatric patient in
• 7:28
  - the world, but there now to date have
• 7:30
  - been 27 other patients
• 7:32
  - who have received a deceased donor transplant.
• 7:35
  - But you're a 100% correct that identifying a
• 7:38
  - donor
• 7:39
  - is,
• 7:40
  - by far the biggest bottleneck in getting a
• 7:43
  - patient successfully to transplant.
• 7:45
  - So there are about ten thousand patients who
• 7:47
  - undergo allo transplant in The United States every
• 7:49
  - year, and every single one of them needs
• 7:51
  - a donor. And so the NMDP,
• 7:55
  - they're they're really
• 7:57
  - outstanding
• 7:59
  - at finding a match for nearly every patient.
• 8:02
  - The problem is that finding a match is
• 8:05
  - only half of it. Right?
• 8:07
  - So just because you have a match in
• 8:09
  - the registry does not necessarily
• 8:11
  - mean that that translates to an available donor
• 8:15
  - who's willing to donate on the timeline that
• 8:17
  - the patient needs it. And I think that's
• 8:19
  - why it becomes such a big barrier is
• 8:21
  - because it's very
• 8:23
  - dependent on willingness, availability
• 8:26
  - of the donor, but also willingness and availability
• 8:28
  - of the donor center.
• 8:30
  - So you can find a donor somewhere out
• 8:32
  - there in the world through the registry, but
• 8:34
  - whether or not the timeline aligns with the
• 8:36
  - patient's needs
• 8:38
  - is very questionable,
• 8:40
  - and often is not as fast as what
• 8:42
  - we would like for it to be.
• 8:44
  - And there are patients who die every year
• 8:45
  - because they can't get a donor on the
• 8:47
  - timeline that's needed.
• 8:50
  - So we are working to fill the gap
• 8:51
  - from a number of different fronts. But when
• 8:54
  - when you're looking specifically about the option for
• 8:57
  - deceased donor transplants, I do think that there
• 8:59
  - is a gap that needs to be filled.
• 9:01
  - And I do think that deceased donor transplant
• 9:04
  - has huge potential
• 9:06
  - for not only helping to fill that gap,
• 9:08
  - but I would even go so far as
• 9:10
  - to say that this could be the preferred
• 9:12
  - way that we do transplants in the future
• 9:14
  - once we have enough data to say data
• 9:17
  - and longevity of data to say that this
• 9:19
  - really is a viable alternative source of cells,
• 9:22
  - and it might even be preferable
• 9:24
  - and more cost effective at at the end
• 9:26
  - of the day.
• 9:28
  - So
• 9:29
  - right at this moment in time, you know,
• 9:31
  - Oceum has been building their deceased donor bank
• 9:34
  - for several years.
• 9:36
  - I don't know exactly how many deceased donors
• 9:38
  - that they have available
• 9:40
  - at any given time, but the number is
• 9:42
  - growing every day.
• 9:44
  - So for con for, you know, context, the
• 9:47
  - NMDP
• 9:48
  - has
• 9:49
  - somewhere
• 9:50
  - near or around the ballpark of 20,000,000,
• 9:54
  - donors that are part of the registry.
• 9:57
  - I think ASEAN, the last time that I
• 9:59
  - talked with them, had somewhere north of a
• 10:02
  - thousand,
• 10:03
  - deceased donors that are banked. And so right
• 10:06
  - at this moment in time, there's not an
• 10:08
  - outstanding chance that you would search the registry
• 10:11
  - and find a perfect match for a patient,
• 10:13
  - but you can search the registry and find
• 10:15
  - an acceptable mass match for a patient.
• 10:17
  - One of the things that we have
• 10:20
  - been working toward in the field for probably
• 10:22
  - the last ten years is utilization
• 10:24
  - of donors that are not a perfect match
• 10:26
  - that we know we can overcome
• 10:28
  - a slight mismatch from a patient,
• 10:32
  - with the use of additional chemotherapy.
• 10:34
  - The problem with that approach, it works very
• 10:36
  - well for getting stem cells to grow. However,
• 10:39
  - the downside is that it's associated with more
• 10:42
  - toxicity, both in terms of side effects from
• 10:44
  - the extra chemotherapy
• 10:46
  - and side effects from the degree of mismatch
• 10:48
  - between the patient and the donor.
• 10:50
  - So
• 10:52
  - for my patient,
• 10:53
  - the the donor that we received from Osteem
• 10:56
  - was not a perfect match, but it was
• 10:58
  - an acceptable match, and that's how we were
• 11:00
  - able to move forward.
• 11:02
  - And I think one of the real benefits
• 11:05
  - in addition to the timeliness and availability of
• 11:08
  - getting a donor that's a deceased donor is
• 11:10
  - also the fact that on the front end,
• 11:12
  - the day that you order
• 11:14
  - the mobilization of the cord from Osium to
• 11:17
  - your center, you know the minute that you
• 11:20
  - place that order what the cell dose is
• 11:21
  - going to be. And that's just not true.
• 11:24
  - When you have an unrelated donor,
• 11:26
  - you get whatever cell dose you get And
• 11:28
  - by the you know, there are things that
• 11:30
  - you can do to stack the duck in
• 11:31
  - your favor, but you never know what you're
• 11:32
  - gonna get until the cells show up to
• 11:34
  - your to your site. And
• 11:36
  - that was, I think, part of the contributing
• 11:39
  - problem for
• 11:40
  - my patient whose first transplant failed is that
• 11:43
  - the cell dose was not as much as
• 11:44
  - what we needed it to be for the
• 11:46
  - condition that we were treating.
• 11:48
  - And when I ordered the donor from Osteem,
• 11:51
  - I knew the minute that I asked them
• 11:53
  - to ship it that I was gonna have
• 11:54
  - enough cells. And and in fact, I had
• 11:56
  - enough sales and some sales left over in
• 11:58
  - the bank that if he he should ever
• 11:59
  - need a boost of sales in the future,
• 12:01
  - we still have some leftover in the freezer,
• 12:03
  - which is incredible.
• 12:06
  - Absolutely. And, you know, you kind of alluded
• 12:08
  - it to
• 12:10
  - what it took to be operationally
• 12:12
  - ready
• 12:13
  - for this.
• 12:14
  - If, you know, this or if slash when
• 12:17
  - this becomes more common
• 12:19
  - to, you know, have a patient from no
• 12:22
  - donor match to transplant in days instead of
• 12:25
  - the weeks or months that we talked about
• 12:27
  - previously.
• 12:28
  - For health system leaders that are listening
• 12:31
  - to this podcast and thinking about
• 12:34
  - what this might do for their own programs,
• 12:37
  - What did it take operationally to be ready
• 12:40
  - to act, and what should leaders be building
• 12:43
  - to make sure that they're ready should they
• 12:45
  - find themselves in a similar situation?
• 12:48
  - Yeah. It's a really good question. So what
• 12:50
  - it took to be ready,
• 12:52
  - is
• 12:54
  - there was a lot of frankly, there was
• 12:55
  - a lot of paperwork that needed to happen.
• 12:57
  - So number one, there needed to be contracts
• 12:59
  - established with ACM through our health care organization.
• 13:03
  - We had to set up contracts for, you
• 13:05
  - know, materials transfer, those sort of things.
• 13:08
  - And then the other thing that, was a
• 13:10
  - lot of work in getting set up was,
• 13:14
  - because deceased donor stem cells are not considered
• 13:17
  - an they're not considered an investigational product by
• 13:20
  - the FDA,
• 13:22
  - but because there there isn't a lot of
• 13:24
  - data around it, many institutions will still want
• 13:27
  - any infusion of deceased donor stem cells to
• 13:29
  - go through
• 13:30
  - their institutional review board process
• 13:33
  - so that it's reviewed and has a formal
• 13:35
  - stamp of approval that this is, you know,
• 13:38
  - to make sure that we're communicating properly to
• 13:40
  - patients, that this is still considered something that
• 13:43
  - is a new therapy,
• 13:44
  - and that we don't really have long term
• 13:46
  - data on the outcomes. But what we do
• 13:48
  - have for early data is very promising. They
• 13:51
  - wanna make sure that we're communicating that properly
• 13:53
  - to patients and that we're tracking
• 13:55
  - outcomes, that we don't just do a deceased
• 13:57
  - donor stem cell transplant and then pray that
• 13:59
  - everything is fine, and it's not until you
• 14:01
  - do 50 of them that you realize that
• 14:02
  - there's a problem. Right? The only way that
• 14:05
  - that happens in a systematic way is through
• 14:07
  - the process of of having an IRB
• 14:10
  - approval
• 14:11
  - for tracking patients. And so our institution, like
• 14:14
  - many others, really wanted this to go through
• 14:16
  - the IRB approval pathway.
• 14:18
  - So getting a institutional approval to proceed
• 14:21
  - was part of it and then writing the
• 14:23
  - consent documents to explain all that I just
• 14:25
  - explained to you to a patient,
• 14:28
  - and having them sign all of those documents
• 14:29
  - and having everything squared away for that, those
• 14:32
  - were the things that took a lot of
• 14:34
  - hours in that one week of time from
• 14:36
  - the time that we knew that we had
• 14:37
  - a potential donor to the time that we
• 14:39
  - were ready to move and ship the cells.
• 14:41
  - I think Aseem would have been more than
• 14:43
  - willing to put the cells bring the cells
• 14:45
  - to us literally the next day. But from
• 14:48
  - the institutional side of things, we still needed
• 14:50
  - to get our ducks in a row. So
• 14:52
  - I think when we think about what it
• 14:54
  - could look like for another institution
• 14:56
  - to mobilize access to this type of donor
• 14:59
  - source,
• 15:01
  - if you really wanted to be proactive so
• 15:02
  - that you don't have a really rough week
• 15:04
  - like I had and, like, my patient waiting,
• 15:07
  - it would be to reach out to Oceum
• 15:08
  - in advance and say, what can we do
• 15:10
  - to be prepared
• 15:12
  - for
• 15:13
  - being able to offer cells
• 15:16
  - if we end up in a similar situation
• 15:17
  - like this? Or if you wanted to be
• 15:19
  - super proactive, you can actually sign up to
• 15:21
  - be part of the clinical trials.
• 15:23
  - So you could reach out and say, Assiim
• 15:25
  - is running formal clinical trials that are more
• 15:29
  - than just an expanded access program,
• 15:31
  - and they are recruiting sites now. So you
• 15:33
  - could reach out to them and say, we
• 15:35
  - would like to be a site. Can we
• 15:37
  - get onboarded for being a clinical trial site?
• 15:42
  - Perfect.
• 15:43
  - I'm gonna shift gears a little bit as
• 15:45
  - we wrapped up the conversation.
• 15:47
  - We've kind of zoomed in on this, you
• 15:49
  - know, specific case, but I'd love to just
• 15:53
  - pick your brain
• 15:54
  - for a kind of broader perspective
• 15:57
  - on
• 15:58
  - pediatric oncology, transplant programs,
• 16:01
  - the pressures that they're facing right now.
• 16:04
  - As you've got an audience of health system
• 16:06
  - leaders, is there anything
• 16:08
  - you feel
• 16:10
  - is not getting enough attention, whether that's, you
• 16:13
  - know, access pressure, funding, staffing?
• 16:16
  - And through the same veins, is there anything
• 16:18
  - you see in the future that leaders might
• 16:20
  - need to tackle when it comes to closing
• 16:22
  - care gaps within pediatric oncology and transplant programs
• 16:26
  - like this?
• 16:29
  - That is a heavyweight question. One. Yeah.
• 16:32
  - So
• 16:33
  - I'll start with, you know, pressures in the
• 16:35
  - field right now and challenges that we're facing.
• 16:39
  - Really, in the field of stem cell transplant,
• 16:41
  - obviously, we've talked about donor access. But I
• 16:44
  - think you can't talk about,
• 16:47
  - challenges and shortfalls in stem cell transplant without
• 16:49
  - talking about what it takes to pull off
• 16:51
  - a transplant successfully.
• 16:53
  - And, really, that starts with having health care
• 16:56
  - team members that have experience.
• 16:59
  - We the nursing shortage is profound
• 17:02
  - across all health care systems.
• 17:04
  - And then when you're
• 17:06
  - trying to deliver these these highly advanced therapies
• 17:10
  - that are highly toxic,
• 17:12
  - having an experienced skill set of nursing
• 17:15
  - and nurse practitioners and physicians and coordinators,
• 17:18
  - all of those people
• 17:20
  - not being new
• 17:22
  - is really critical. And so I think,
• 17:25
  - health care systems valuing the experience that they
• 17:28
  - have and their existing team members and working
• 17:30
  - to retain. I know everybody wants to retain
• 17:33
  - their nurses,
• 17:34
  - but, and everybody is working on the short
• 17:36
  - fallings that we have in staffing. But in
• 17:39
  - a field like this, where experience is sometimes
• 17:42
  - the difference between life and death, we have
• 17:45
  - to prioritize
• 17:46
  - retaining experience. So I think that's probably one
• 17:49
  - really big thing.
• 17:51
  - I think
• 17:52
  - in terms of, you know,
• 17:55
  - other system challenges, I think, you know,
• 17:58
  - the cost of these type of therapies of
• 18:00
  - advanced therapeutics, like stem cell transplant, CAR t
• 18:03
  - cell therapy, gene therapy,
• 18:06
  - both inside and outside of cancer care require
• 18:09
  - really innovative thinking and budgetary planning.
• 18:12
  - And I think, you know, we're in the
• 18:13
  - midst of these conversations with our own health
• 18:15
  - care system right now of, you know, health
• 18:18
  - care as a whole is really struggling financially
• 18:20
  - right now. And there are lots of reasons
• 18:22
  - for that, but I think,
• 18:25
  - being strategic in what we invest in
• 18:29
  - and,
• 18:30
  - being,
• 18:31
  - you know, thoughtful about
• 18:34
  - where we place our dollars and cents,
• 18:37
  - in order to provide care to patients
• 18:40
  - and,
• 18:41
  - specifically, to provide equitable access to care is
• 18:44
  - another really big piece of things.
• 18:48
  - And that requires having
• 18:50
  - proactive conversations
• 18:52
  - with public payers specifically,
• 18:55
  - in order to ensure continued equitable access to
• 18:57
  - care.
• 18:59
  - I think in terms of
• 19:01
  - what we're, like, looking at in the field
• 19:03
  - and closing gaps in
• 19:06
  - care as they currently exist of,
• 19:09
  - where the science is versus where we wanna
• 19:11
  - be. When we really think about what therapeutics
• 19:14
  - are available to us, I think we have
• 19:16
  - amazing tools in our toolbox
• 19:18
  - and working to move those tools a little
• 19:21
  - earlier in care so that patients don't come
• 19:23
  - to us
• 19:24
  - with, you
• 19:26
  - know, existing organ damage or existing toxicity that
• 19:30
  - makes their care more complicated
• 19:32
  - would be beneficial
• 19:33
  - for patient care. The rub and the challenge
• 19:35
  - in that is that those advanced therapeutics are
• 19:37
  - more expensive.
• 19:39
  - So trying to balance, you know, who really
• 19:41
  - needs these therapies and how can we integrate
• 19:43
  - them in a way that financially makes sense
• 19:46
  - both for patients and health care systems is
• 19:49
  - it's a big challenge if I'm being really
• 19:50
  - honest.
• 19:53
  - And then within the science of where it
• 19:55
  - currently exists within I'll speak specifically to cancer
• 19:58
  - because that's what I do.
• 20:00
  - Mhmm. You know, we've gotten pretty good at
• 20:03
  - using advanced therapeutics,
• 20:04
  - like cell therapy and gene therapy
• 20:07
  - for
• 20:09
  - hematologic malignancies, so leukemias, lymphomas, that sort of
• 20:12
  - thing. But there are still very large challenges
• 20:15
  - that exist in the realm of solid tumors,
• 20:18
  - which are actually much greater in number than
• 20:20
  - hematologic malignancies.
• 20:22
  - So,
• 20:23
  - we're working to we're working with our bench
• 20:26
  - scientists to advance to next generation CAR T
• 20:29
  - cell therapies that can
• 20:30
  - address some of those shortcomings.
• 20:33
  - And then the other thing that we really
• 20:35
  - have to figure out is how to deliver
• 20:36
  - this care
• 20:38
  - less expensively.
• 20:39
  - Mhmm. So,
• 20:41
  - we are you know, that's another area where
• 20:43
  - science is working so that we can do
• 20:45
  - this therapy and not break the bank in
• 20:47
  - doing it,
• 20:49
  - because there will be ways to streamline this
• 20:51
  - therapy moving forward
• 20:53
  - that will be less
• 20:55
  - costly and less labor intensive,
• 20:58
  - and that will help provide equitable access to
• 21:00
  - care as well.
• 21:02
  - So
• 21:03
  - those are just some of the musings off
• 21:04
  - the you know? Yeah. Off of what I
• 21:06
  - see every day, but I think,
• 21:08
  - that there are gaps to be filled is
• 21:10
  - not a question.
• 21:11
  - Absolutely. And, you know, that's what I love
• 21:14
  - about having these conversations on the podcast because
• 21:16
  - you are able to share, you know,
• 21:18
  - your musings based on what you're seeing, and
• 21:20
  - I know that it resonates with, you know,
• 21:22
  - other oncology leaders across the country. So I'm
• 21:26
  - so grateful, doctor Scowles, that you took the
• 21:28
  - time to come on the podcast to share
• 21:31
  - more details behind this case, but also just
• 21:33
  - your insights. Overall, I hope we can connect
• 21:35
  - again soon.
• 21:37
  - Absolutely. Thank you for having me.
• 21:39
  - And thank you to our listeners for tuning
• 21:41
  - in to Becker's Oncology Leadership Podcast.
• 21:44
  - I invite you all to check out even
• 21:45
  - more Becker's Healthcare Podcasts at breccarspodcasts.com.
• 21:50
  - Thank you again to doctor Styles for joining
• 21:52
  - me, and thank you to our listeners for
• 21:53
  - tuning in. Have a good day.