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Standardizing MUM Surveillance: COOG Panel Discussion | The Eye Believe Podcast · The Eye Believe Podcast

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hey everyone
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welcome to another episode of the Eye Believe Podcast
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and this one is extra special
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because we are bringing you some very cutting edge
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updated information from some amazing doctors
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so i'm gonna have them introduce themselves
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and then we're gonna get into what we're talking about
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hi my name is Dr. Juan Alban
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i'm a chief hematology oncology fellow
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at Northwestern University
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hi i'm Dr. Sunandana Chandra
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i'm a melanoma medical oncologist at Northwestern
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i'm Dr. Scott Walter i'm a ocular oncologist in Hartford
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Connecticut hello
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i'm Dr. Jose Lutzky i'm a medical oncologist
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specializing in melanoma at the University of Miami
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Sylvester Cancer Center hi
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i'm Dr. Meredith McKean i'm a medical oncologist uh
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based here in Nashville uh
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with Sarah Cannon Research Institute
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yeah hi
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i'm Dr. Sanjay Chandrasekaran
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and i'm a medical oncologist at UT Southwestern
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in Dallas, Texas
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welcome everybody
0:53
and thank you so much for being here
0:55
this means a lot to patients caregivers
0:58
everyone that's experienced ocular melanoma
1:00
that you guys are putting so much effort and dedication
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into not only taking care of patients
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but trying to help find a cure
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so we're very appreciative of your time and your
1:09
everything you're doing but also
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that you're taking time out of your day
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to be here with us and explain this to patients
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this is huge that you're doing this
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and we're very very grateful
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so would you guys like to give a little background
1:23
on what COOG is
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because some people listening right now might be like
1:27
oh i've never heard of COOG
1:29
yeah so
1:30
the COOG
1:30
stands for the Collaborative Ocular Oncology Group
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uh this started off as kind of
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a small group of ocular oncologists
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who were uh
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you know scientifically uh
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curious and aligned with the work of uh
1:45
Dr. Bill Harbour J. William Harbour
1:49
who is known for developing
1:51
the gene expression profiling test
1:53
which has now kind of become widely used
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as a standard of care in the united states
1:59
for prognostication in uveal melanoma
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and so you know
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Bill's work kind of developed this test and then uh
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led to prospective validation of the test uh
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through uh
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a collaboration between multiple centers
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and uh over the
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the subsequent years that's kind of evolved into um
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additional testing modalities
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so probably heard about prame expression
2:21
and more recently the uh
2:24
next generation sequencing
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for uveal melanoma associated mutations
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and so the group has grown
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both in terms of
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the number of affiliated ocular oncologists and
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and the
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the number of tests that we've validated prospectively
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through this venture and then over the past
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you know four or five years
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we started uh expanding our meeting to invite uh
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medical oncologists uh
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many of the uh
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you know premier ocular oncologists in our group
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are affiliated with
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really top notch medical oncologists
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and we wanted to bring them into the fold
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to learn from them more about
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you know what happens after we treat the eye
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melanoma and
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you know how we can make a difference in terms of um
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uh metastatic disease cause
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ultimately that's really what
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you know we care most about
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and so you know
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over the past several years
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we've had these very productive discussions
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at the meeting and um
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i think you know
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Bill Harbour and some of the other leaders in the group
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kind of came up with the idea
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of putting together a panel
3:27
to come up with some consensus guidelines
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around meta saga surveillance
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so Juan kind of took the lead on this project
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and i'll kind of handed over to him
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to explain the methodology and
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and who all was included in this consensus group
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excellent
3:43
so this project was a fairly large
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it spanned about one year
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um
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we invited forty nine experts from around the country
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um so experts who were medical oncologist
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ocular oncologist surgical oncologist and radiologist
3:57
um to participate in this project
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the delphi uh method
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it's a method
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that was developed in the nineteen fifties initially uh
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and it's a technique to achieve consensus
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among a group of experts
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it involves multiple rounds of questionnaires
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where experts anonymously
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provide their opinions and feedback
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after each round
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experts are provided a summary of responses
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and then are invited into a debriefing session
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so that we can have all the experts
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discuss the results of each questionnaire
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and revise our views
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we ultimately did this three separate times
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across the year uh
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which ultimately gave us the consensus document
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that has recently been published
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so Juan
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you make a great point and
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and also let's not forget
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that this was actually a multinational effort
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because our colleagues in Canada were also able to join
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you know what led to this endeavor was the recognition
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at one of our COOG meetings
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or actually multiple meetings
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that we were all surveilling our patients
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in various ways
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using different types of imaging methods or modalities
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different types of frequencies
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and we realized very quickly
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that it behooves our patients
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and the field in general
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to try to develop some sort of consensus
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to help guide us and our colleagues
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and also to give our patients
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a sense of how best to manage their surveillance
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now of course
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the problem is that there's not a lot of evidence
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behind these guidelines
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it's a mix of data that Scott had alluded to
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the gene expression profile data
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the prame data
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that can help us prognosticate someone's survival
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who has uveal melanoma and
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it was also a combination of everyone's expert opinion
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from all these different multidisciplinary groups
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to come up with some sort of consensus
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that we can all then follow um
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to the best of our ability
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i might also add that for a long time
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there was a lot of questioning on
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why do we need to do this
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why do we even have to do imaging
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or why do we have to follow patients
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because we don't have any treatment for them
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but that has changed currently
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we are living in one of the most productive periods
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scientifically in understanding melanoma
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uveal melanoma in particular
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there's a lot of research there
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a lot of new potential treatments that
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and some that have already been proven to be beneficial
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so in this current environment
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it's very important to know
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who is at high risk of recurring
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and who is not so i think that also uh
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is prompted us to feel the urgency
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of trying to find a framework
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where we can all speak the same language
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i think that's fantastic so
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you all have gotten together
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and published a paper with the guidelines
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and it is called
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the Metastatic Uveal Melanoma Surveillance
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A Delphi Panel Consensus
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can you explain to us what a delphi method is
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and why you used it
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most definitely so the delphi method
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it's it's a wonderful method to utilize
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when there isn't a clear um
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right answer and you're trying to answer the question
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with many different viewpoints
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so in this situation as jose just mentioned
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everyone's doing things a little bit differently
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and everyone's got their own reasonings
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and so
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we wanted to sit down and create an iterative process
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or format
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in which we could tease out these differences uh
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in practice patterns
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and try to actually standardize those practice patterns
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across the board uh
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in the us and canada so the stealthy method
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this technique to achieve consensus
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it's really just an iterative um
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multiple rounds of questionnaires
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so we create a questionnaire with a um
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with numerous different recommendations
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and we pass them on to our panelists
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and we have them rate from one to nine
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what degree
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they agreed with the statement in front of them
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based on those scores we then went back
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and discussed each round of the questionaires
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with our panelist so that everyone could understand
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what specific recommendations were popular
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what recommendations were unpopular
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and how we could tweak them to improve them
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so that we could get the largest amount of members
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on board with the set recommendations
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that were ultimately published
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so this method
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it really allowed us to go back to the drawing board
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numerous times
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with the feedback from a very diverse group of experts
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and ultimately craft very descriptive statement
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recommendations for each class of patients
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the intermediate risk and the high risk patients
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so we dive into not just the frequency of surveillance
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but also the techniques
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so what imaging modalities should be utilized
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if and when blood testing should be utilized
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and if and when pet ct should be utilized
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i'll just jump in there you know
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i'm you know
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kind of a private practice ocular oncologist
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out in the community setting
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and so you know
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my patients don't necessarily
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all have the benefit of going to a world expert
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a medical oncologist who specializes in uveal melanoma
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right they're
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they're more likely to see a
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a general medical oncologist or
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you know maybe a
10:09
if they're lucky a
10:10
a medical oncologist
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that specializes in cutaneous melanoma um
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but they're less familiar with
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with uveal melanoma surveillance
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and so there's a lot of heterogeneity out there
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you know even
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you know we're talking amongst the experts in the group
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you know there was disagreement
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but when you get out to the community
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ocular oncologist there's
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or sorry
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medical oncologist there's even more variability
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in how surveillance is being done and
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and so one of the things that
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you know i think this has helped with is
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you know providing
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sort of
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clear guidelines that we can send to a community uh
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oncologist to help
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allow them to do this surveillance
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in a way that is in alignment with the uh
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world experts you know
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that that join the panel
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and do you feel like because uveal melanoma is so rare
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that that makes it more challenging
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absolutely because
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most medical oncologists
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have probably never seen a case of uveal melanoma
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in their careers you know
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they kind of get siloed into the more common cancers
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and you know
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unless they're in a major center
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where these patients are concentrated
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they're unlikely to have managed this disease in
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in terms of surveillance or
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you know the
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the management of active
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metastatic disease once it occurs
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another potential advantage of this and
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and a very practical one is that for
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and i would ask my colleagues to
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to give their input here is is uh
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in terms of getting insurance approval
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for some of the test
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some some
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and it's very inconsistent there
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some insurance companies will approve
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what we think
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is the best imaging modality for the patient
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while others will not so
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we're hoping if we can create this framework there
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that's published there and
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you know it has the agreement of forty plus uh
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physicians that specialize in the field
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it would make it easier for us to argue
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with these insurance companies
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but i don't know what Meredith or Sanjay
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have to say about that
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yeah i think not only is it important for um
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you know other colleagues
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medical oncologists um
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patients but also insurance companies
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to educate all of them on the differences
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between cutaneous and uveal melanoma
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right and how um
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how we determine high risk cutaneous melanoma
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is very different than uveal melanoma
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how we follow it's very different
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and so
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i think the more we can highlight those differences
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the more we can um
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really advocate for our patients and be able to say
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look we know the risk of recurrence in the liver is the
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you know the most concerning location
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and so this is why we need to follow patients with um
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intensive monitoring in the liver um
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for example with mri of the liver
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triple phase ct
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and especially for the patients that
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with the risk prognostic uh
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scores that we have now
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we know which patients are at higher risk
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and which ones
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we need to be more intensive in our screenings
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versus patients that are low risk
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that we can say you know
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you don't need that same level of intensity
13:21
in your follow up traditionally
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or historically i should say
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uveal melanoma was more of a clinical diagnosis
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but yet over the past few years
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we have some very clear and clean data
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showing us that perhaps if we had some more
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um biopsies being done
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and we had some tissue to actually analyze
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we could really prognosticate people who are at low
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medium and high risk or what we call low
13:52
intermediate or high risk
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so also one of my hopes with this
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you know um
13:59
consensus document um
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is that it will encourage many of our colleagues
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who are around the uh uh
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country to actually uh
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consider doing a biopsy
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because that actually would change surveillance and
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and it can have quite a significant impact
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on whether someone's low risk or high risk
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one of the nice things about the way the delphi is
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is presented and and bearing in mind we
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we have national guidelines for uveal melanoma
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and as there
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there are committees that sit down and review this
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but i think for practicing oncologists that are
14:34
that are working through national guidelines it
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it's nice to have in a way
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something that you can read
14:39
that's a conversation amongst physicians
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who are making these decisions
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and recommending how to make those decisions
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and that's why as
14:47
as the way the delphi uh
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publication is presented
14:50
it kind of works through these scenarios to finally say
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hey
14:52
this is how the group achieved these recommendations
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so it
14:57
it's less of an ingredients list and more of a recipe
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to to allow someone to work through
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work through the scenario
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and i think that that's why it's
15:05
it's very complimentary to what exists and
15:08
and certainly
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i think offers context to both providers and patients
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and payers and family members
15:16
as to why we're doing what we're doing
15:18
and the decisions are being made
15:20
i think that's amazing and so needed
15:23
Dr. McKean can you walk us through the pattern
15:25
of metastatic spread yeah
15:27
so unlike um
15:29
other cancers where we can check a lymph node
15:32
say at the time of diagnosis
15:34
and uveal melanoma
15:35
we're limited to features of the primary tumor
15:39
to understand risk factors and
15:41
and the and the biopsy um
15:43
because uveal melanoma
15:44
is more likely to spread through the blood
15:46
and so um
15:48
because of this
15:49
the biggest concern is that this cancer can um
15:53
return in the liver and often times
15:57
patients don't have any symptoms
15:59
their labs may be normal um
16:02
if blood work is checked and so um
16:04
this is why we need intensive monitoring of the liver
16:08
other locations that uveal melanoma can um
16:11
recur is places like the lungs bone
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other places in the abdomen
16:16
and so we need comprehensive imaging
16:19
but it really does center on good imaging of the liver
16:23
um in addition to these other locations
16:26
uveal melanoma as a rare disease
16:28
we haven't had you know
16:30
randomized trials
16:31
to be able to look at different screening mechanisms
16:35
and so a lot of this
16:36
is based on our clinical care of patients
16:39
and what we've seen as the best test
16:42
to be able to detect metastatic disease
16:44
one of the great tools that we have now
16:46
is this gene expression profiling and prame
16:49
which we're using uh
16:51
clinically to help uh
16:52
estimate the likelihood
16:54
of a metastatic disease progression
16:56
so at the time of a tumor diagnosis
16:59
an ocular oncologist
17:01
often will perform a biopsy of the tumor
17:04
and send uh
17:05
some genetic material for uh
17:07
gene expression profiling
17:09
and that comes back with a result of either class one
17:12
or class two uh
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in addition uh
17:15
we now also do prame expression profiling
17:18
on the same specimen
17:19
so that further subdivides patients into class one
17:23
prame negative which is the lowest risk subgroup
17:26
those patients have a less than five percent risk
17:30
of developing metastatic disease progression
17:32
over five years
17:34
the second uh
17:35
group is class one prame positive
17:38
so these patients still have a relatively low risk
17:41
of metastatic disease progression
17:43
but it's about twenty percent of patients
17:46
who will develop metastatic disease
17:47
over the course of five years
17:49
and the uh
17:50
average time to develop metastasis in this population
17:54
is about three years from diagnosis
17:56
then we get into the class two tumors
17:58
unfortunately class two tumors
18:00
have a much higher likelihood of metastasizing
18:03
it's around fifty percent of these patients
18:05
will go on to develop metastatic disease
18:08
and if we subdivide the class two population
18:11
into the prame negative
18:12
versus prame positive subpopulations
18:15
there's a slightly lower risk of disease progression
18:18
in class two prame negative
18:20
versus the higher rate of disease progression
18:23
in class two prame positive
18:25
so um
18:26
basically
18:27
the patients who are class two prame positive
18:29
are our highest risk group
18:30
they have a you know
18:32
roughly sixty percent chance
18:34
of developing metastatic disease within five years
18:37
and about half of the patients
18:38
who will develop metastatic disease
18:40
will do so within a year and a half of diagnosis
18:43
so the latency to metastasis is also shorter
18:46
in the class two prame positive subgroup
18:49
in the class two prame negative subgroup
18:53
it's a little under fifty percent of patients
18:55
who will develop metastatic disease
18:57
and the the latency is a little longer
18:59
so the average time to developing metastatic disease
19:01
is about two years from diagnosis
19:04
so this
19:05
the availability of this really detailed algorithm for
19:09
uh determining metastatic risk
19:11
has allowed us to develop
19:14
more personalized surveillance guidelines
19:16
for patients in different risk categories
19:18
and that's really uh
19:20
what this consensus is all about
19:22
i think it's interesting to notice also
19:24
that for some of these subgroups
19:26
that don't have a very high recurrence rate
19:30
some of these patients may recur late uh
19:34
sometimes ten years later
19:36
so recognizing this we included uh
19:40
long term surveillance in
19:42
in these guidelines that
19:44
the main reason why we wanna know
19:46
who is going to recur and when
19:49
is because we may have the opportunity to intervene
19:53
to prevent those recurrences
19:54
and there are we're beginning to see now
19:58
new clinical trials that
20:00
trying to prevent or delay recurrence
20:03
in those very high risk cases
20:05
so i think at this point
20:07
we can discuss a little bit of our findings
20:10
and the consensus recommendations
20:13
so if we break down our recommendations
20:15
based on the risk classification
20:17
let's quickly revisit what that risk classification is
20:20
so for the intermediate risk
20:22
these are patients who are class one
20:23
by gene expression profile
20:25
in prame positive or Disomy 3
20:28
with gain of chromosome 8q
20:30
or SF3B1 mutation
20:33
or if we use the AJCC classification
20:37
this would be a T2 or T3 tumor
20:42
for these patients we recommend that they undergo
20:45
screening for metastatic disease
20:46
with a frequency of every three to six months
20:48
for five years
20:49
and thereafter annually for at least ten years
20:52
from diagnosis
20:53
we recommend that they undergo cross sectional imaging
20:57
meaning ct abdomen or mri abdomen
21:01
to surveil for metastatic disease
21:03
specifically in the liver
21:06
we do note that we have a preference towards contrast
21:09
enhanced mri abdomen over ct abdomen
21:13
and also over hepatic ultrasound
21:17
with regards to surveillance of the thorax
21:20
or the chest
21:20
we recommend that patients undergo a ct of the chest
21:24
which is combined with this hepatic imaging
21:26
but we don't dictate the specific frequency
21:30
or the ct of the chest
21:32
meaning that patients can undergo ct chest
21:35
um at a reduced frequency
21:36
in comparison to the abdominal imaging
21:40
now with regards to the high risk group
21:43
the high risk patients are those who are class two
21:46
by gene expression profile
21:48
regardless of their prame
21:51
meaning prame positive or prame negative
21:54
they can also fall into this high risk group
21:56
if they have monosomy 3
21:58
regardless of chromosome a q
22:01
have a Bap1 mutation or are T4 by AJCC
22:07
for these patients we recommend an increased frequency
22:10
we want them to undergo metastatic disease surveillance
22:15
with a minimum frequency of every three to six months
22:17
for years one through five
22:19
then
22:19
every six to twelve months for years six through ten
22:22
and then surveillance imaging beyond ten years
22:25
can be considered
22:27
for these patients
22:28
we similarly recommend the use of contrast
22:30
enhanced ct abdomen or mri
22:33
over the use of a hepatic ultrasound
22:36
for these patients
22:37
we also recommend the use of a ct chest
22:39
which can be combined with hepatic imaging
22:41
for surveillance of metastatic disease in the thorax
22:45
although
22:45
this can also be performed at a reduced frequency
22:49
lastly we similarly note
22:50
that we have a preference towards mri of the abdomen
22:53
over ct abdomen in this high risk population
22:57
if we take a step away from our risk classifications
23:00
we did also provide some general guidelines
23:03
regardless of the risk classes
23:05
with regards to pet ct's
23:07
we did not feel that they were reliable enough
23:10
in picking up
23:12
the small amount of metastasis to the liver
23:16
and so as a result
23:16
we recommend the use of mri or ct abdomen in its place
23:21
with regards to uh
23:22
hepatic ultrasound or ultrasound of the liver
23:25
unfortunately
23:26
this tends to be a very technically difficult exam
23:30
and is very much dependent
23:32
on the expertise of the ultrasonographer
23:36
and so as a result
23:37
we feel that there's too much variability
23:39
in that test's capacity to pick up metastatic disease
23:43
so similarly we recommend the use of mri or ct
23:46
in place of hepatic unltrasound
23:49
and lastly we did not feel that the routine blood work
23:54
uh necessarily added much uh
23:57
in ways of picking up uh
23:59
metastatic disease meaning
24:01
it is more often than not
24:04
that these tests
24:05
do not provide us any additional information uh
24:08
when done on a routine basis
24:11
so i think one thing that's important to realize
24:13
and for our patients to understand
24:16
is not every anatomic part of the body
24:21
can be imaged identically compared to another part
24:24
so for example
24:26
for the abdomen and pelvis
24:27
we often use contrast to really help delineate
24:32
you know small structures
24:33
and gives us a lot of detail
24:35
it's highly sensitive highly specific however
24:38
for example for the lungs
24:40
for the chest especially
24:42
if we're not necessarily concerned about lymph
24:44
nodal involvement we actually don't need contrast
24:47
so those are just examples of
24:49
we just have to be very thoughtful
24:51
when we're ordering these different imaging tests
24:54
to make sure that we A. order the best test possible
24:58
to give us the most information and
25:00
and B. spare our patients additional tests
25:03
that may not be that much more meaningful
25:06
Juan
25:06
you would mention prognostic factors that we look at
25:08
other than just gene expression profile
25:10
you know you mentioned prame
25:12
you mentioned chromosomal analysis
25:14
the genetics of the tumor
25:16
the tumor size i think it bears worth repeating
25:20
that having it be a variety of prognostic factors
25:25
and have that being included in this document
25:27
we hope will allow more people to be able to use it
25:32
because we acknowledge that
25:34
not everyone has access to gene expression profiling
25:37
different centers may have different protocols
25:39
when trying to prognosticate the tumors
25:41
so i think this document
25:43
allows for multiple variables to be taken into account
25:48
and then finally
25:49
what sets uveal melanoma apart from many other cancers
25:52
is that it can have a long latency in some um
25:57
scenarios
25:58
and so extending our scan frequency when appropriate
26:03
i think will also help keep our patients safe
26:07
with respect to helping us detect recurrences
26:12
i think another
26:13
an interesting finding from this was it did
26:16
i think
26:17
deescalate um
26:20
surveillance imaging for some patients
26:22
so the analysis showed that uh
26:24
while the national guidelines
26:26
for patients that are class 1 B
26:29
by GEP
26:31
but don't have prame expression
26:32
were initially thought to be
26:34
an intermediate risk category with
26:36
with a higher risk for developing disease
26:39
the based purely off of the the
26:42
the collaborative oncology group report number two
26:46
using that data and using a consensus statement
26:49
we can i think
26:49
confidently say hey
26:51
those those are patients
26:52
where we may not need to scan as frequently
26:54
that if it's class 1B prame negative
26:57
that's actually a low risk population
27:00
that a consensus group feels
27:01
that this is a space where we could move from a
27:04
a six month interval maybe even
27:07
even deescalating well
27:09
again the consensus group at least
27:11
didn't completely finalize
27:13
what low risk patients should ideally um
27:17
be receiving in terms of scans
27:19
i think it's it's nice for patients to understand hey
27:22
maybe my risk is a little bit better
27:24
maybe i'm i
27:25
i have a better chance of beating this
27:28
and not developing recurrence of my melanoma
27:32
you know one thing that comes up often in clinic is so
27:35
the time toxicity and the financial toxicity
27:38
of all the testing that we do
27:40
so for a lot of our patients at northwestern
27:42
they're traveling from really
27:44
quite far away to see us in the clinic
27:47
and so if we are recommending imaging
27:51
you know that is an additional trip
27:53
often to the downtown center
27:55
and so now being able to point to an expert consensus
28:00
and feel very confident in the recommendations
28:02
that we're providing to patients
28:05
makes the discussions a lot easier for us in the clinic
28:08
not just to provide support
28:10
but also to counsel patients
28:11
if they're spending hours or days
28:14
performing the tests that we're asking of them
28:17
then i think
28:17
it's really important
28:18
that we have the best data out there
28:21
to really guide those decisions
28:22
and so i'm very glad that now through this effort
28:25
we can really provide those recommendations
28:28
and those frequencies with very high confidence
28:32
can i ask you as a wrap up question
28:34
what's next for COOG
28:36
i think one i mean
28:37
one of the questions that persists is
28:40
just how long do we continue to surveil patients
28:43
because the the goal of the um
28:46
the COOG data and how to implement that
28:48
as we discussed is
28:49
to not only understand
28:50
which patients to intensify screening
28:52
but also which patients to deintensify
28:54
and so right now the consensus was
28:58
that it really should be up to the individual
29:01
the provider high risk patients
29:03
we've started to give guidelines up to ten years
29:06
but i i see
29:08
that is one of the issues
29:09
that i hope that we are able to address
29:12
even better in the future
29:14
once we have longer follow up of these patients that um
29:17
have been participating in the COOG data
29:19
that makes a lot of sense
29:21
is there anything else you guys want to touch before we
29:23
wrap up so i think this effort really highlights how
29:28
when a group of experts come together and
29:31
and identify an unmet need
29:33
in this case
29:35
some further guidance for how to surveil our patients
29:39
based on the data that we do have available
29:42
that you can achieve the the objective
29:45
and so you know i
29:46
i hope that this document
29:48
this consensus guideline is actually helpful
29:51
not only to our colleagues around the country
29:53
but also most importantly
29:55
for our patients another
29:57
benefit of this is that if
30:00
if it gets adopted by other medical oncologists
30:04
particularly
30:04
the people that are not that familiar with uveal melanoma
30:07
it will create a database
30:10
that we can do real world assessments
30:15
in a much more a reliable way
30:17
because right now if you want to see in the real world
30:21
how our patients are doing
30:23
they got a specific treatment
30:24
for example
30:25
if people are being assessed at different intervals
30:28
different types of imaging
30:31
it may not be very reliable
30:33
and that's why
30:35
standardization of monitoring of patients is important
30:39
and i think ultimately you know
30:41
we wanna go back to thanking patients right
30:43
if um
30:44
it was because patients have all signed up to say yes
30:48
i wanna participate in the COOG
30:51
you know
30:51
study and please um
30:54
use my data to help other patients
30:56
that we now have all this information
30:58
that we can look back and try to develop
31:00
these guidelines and patients were signing up for this
31:04
well before as Dr. Lutzky said
31:06
well before we had any effective treatments um
31:09
but it was you know
31:11
that those those patients that um
31:14
donated their time effort and allowed us to
31:18
to follow them and to look at their data
31:20
that we now have this really robust data set
31:23
that helps inform um
31:25
surveillance patterns helps us identify
31:27
hopefully high risk patients for adjuvant trials
31:30
it's always interesting at patients in clinic if they
31:33
you know we get to the five year mark and they say
31:35
what do we do and i say
31:36
well thanks to you
31:37
we're getting more more information and a better idea
31:40
and you know
31:41
they say oh what what
31:41
what am i participating in
31:43
cause i know at time diagnosis it's
31:45
it's can be very overwhelming
31:47
and it's a a patient saying sure what
31:49
you know what else can i do to help um
31:51
at that moment but
31:52
it really all comes back to those patients
31:54
being so thankless um
31:56
with their with their time and
31:57
and all their information
31:59
absolutely
32:01
thank you all so much for being here
32:02
and explaining this to us
32:04
in a real world way
32:05
that a patient can actually understand it
32:07
because it's such valuable information
32:10
and i think that patients hear about this
32:11
and they get so excited
32:12
but they don't know how to access the information
32:14
or how to you know
32:16
make it understandable or digestible
32:18
so the fact that you guys came
32:20
and explain this to us and took time out of your day
32:22
it means the world to all of us and we're so grateful
32:25
so thank you so very much for everyone watching
32:28
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32:30
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33:33
i hope you all have a wonderful week
33:35
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