Latest / The Eye Believe Podcast / Eye on the Expert: Eye on ctDNA – What Doctors Are Learning in Uveal Melanoma

Transcript

Eye on the Expert: Eye on ctDNA – What Doctors Are Learning in Uveal Melanoma · The Eye Believe Podcast

0:03
all right everybody
0:04
um we are kicking off our quarter 2 webinar the Eye On
0:08
CT DNA and I know it's a little bit of a pun
0:10
for us to use that all the time but we are so
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excited to have the guest speakers that we have today
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um I wanted to start off by thanking you guys our audience
0:18
everybody who registered and who
0:20
has started participating um
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I am so grateful to you guys for you know just
0:26
playing an active role in your care
0:28
and in what you learn as patients and caregivers
0:30
in the uveal melanoma community
0:32
so um we here at A Cure In Sight are so
0:34
excited to bring this webinar topic to you about CT
0:36
DNA and just kind of helping you understand
0:38
what this test is and how you might um
0:41
potentially bring it to your doctor
0:42
as something that you could utilize in your own
0:44
um medical journey as a uveal melanoma patient so um
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to kick us off I want to just say huge thanks to our
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sponsors
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um we have quite a number of sponsors this time
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we've got Natera Castle Bio Sciences
0:59
Aura Bio Sciences Delcath Systems Ideaya Bio
1:02
Sciences and Immunocore who are all helping to sponsor
1:05
this webinar
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um and who are just making this possible so
1:08
big shout out to them for making this possible
1:10
and thank you to all of you guys who are registering
1:12
who are here live and listening
1:14
um as we get started and I bring on our guests
1:16
we are going to have a short presentation to start
1:19
and then we are going to have an opportunity for you guys to ask questions
1:22
as you have questions
1:23
you know as Doctor Krainock is presenting um as you hear
1:26
you know the doctor's discussing
1:28
please make sure to put those in the Q&A box
1:30
there should be a section at the bottom where you can
1:32
click to ask a Q&A or you can uh
1:36
you can ask in the chat as well I will be monitoring
1:38
both of those places and we will answer questions
1:41
throughout and throughout the end of the portion of the webinar
1:45
um
1:45
we do have a hard cut off at the hour and a half mark
1:47
or the hour or
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yeah hour and 15 minute Mark goodness I gotta
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calculate time here
1:52
um but as you guys are popping into the webinar
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drop in the chat where you're from
1:55
you guys should be able to chat and just say hi
1:58
um but with that I'm gonna go ahead and bring our friends
2:01
and our guests into the webinar
2:03
thank you guys for joining us um
2:04
we're gonna actually do a little bit of an introduction
2:06
round table style so um
2:09
you guys know who I am I'm Danet Peterson with A Cure
2:11
In Sight and I'm your host
2:12
for this webinar and my kind of co host in this
2:15
in this webinar is Doctor
2:17
Michael Krainock from Natera so um Doctor Krainock say hi
2:21
hi everybody
2:22
I'm Mike Krainock
2:24
Medical Director at Natera super excited to be here
2:26
uh Doctor Montazeri you wanna go next yeah hi uh
2:30
my name is Kam Montazeri I'm a
2:32
melanoma oncologist at Mass General
2:34
Brigham Cancer Institute and faculty at Harvard
2:38
Medical School I have a special focus in uveal melanoma and I'm
2:42
really happy to be here and thank you for the audience
2:45
to join
2:45
Doctor Ma
2:46
yeah hi uh good afternoon everyone
2:49
uh my name is Vince Ma
2:50
I'm a medical oncologist at the university of Wisconsin
2:53
Carbone Cancer Center uh currently the co
2:56
faculty lead for melanoma and non melanoma skin cancer
3:00
um and one of my areas of um
3:02
special interest and focus
3:04
particularly in research is also in
3:07
uveal melanoma so I'm glad to be here today to to
3:11
to answer some great questions
3:13
awesome thank you guys so much for being here
3:15
again for just participating and um
3:17
with that let's go ahead and get started with Doctor
3:19
Krainock's presentation
3:20
and we'll just learn a little bit more about Natera
3:22
and the signatera test
3:24
sounds great thanks Danet can everybody see the slides
3:27
OK they're coming through alright on your end
3:29
alright wonderful um so once again I'm Mike um I'm a
3:34
physician scientist and surgeon
3:35
by background I've been with the company about
3:38
six years now
3:39
I do a lot of work in melanoma
3:42
and other cutaneous oncology as well as
3:45
thoracic oncology and head and neck oncology um
3:49
I'm gonna start just by kind of giving you guys a background
3:52
of the the product
3:54
portfolio so to speak that that Natera has
3:58
and then we'll kind of focus in on
4:00
one piece of what we do which is
4:02
molecular residual disease testing or MRD
4:05
and talk about how we do that and why we do that and what we're learning
4:10
by doing that
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we'll look at some data in all types of cancer
4:14
and then we'll kind of focus down from there
4:17
and look at data across different kinds of melanoma
4:21
to include some uveal patients
4:23
um and then I'll pass it off to Doctor
4:25
Montazeri and Doctor Ma
4:27
um to kind of talk about specific cases
4:30
and their specific experiences they've had in in
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uveal melanoma specifically
4:35
and then we should have some time for some questions
4:38
so hopefully by the end you've got a really good sense of kind of what this technology is
4:42
the state of the field
4:44
and also the the the clinical data and potential
4:47
clinical utilities in in melanoma and uveal melanoma
4:51
so
4:53
what you're looking at here is kind of a menu of tests
4:55
that Natera has for cancer diagnostics
4:58
I'm actually gonna start with the test called Altera
5:01
so that's a comprehensive genomic profiling test
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this is what a doctor
5:05
would get when they want to know if there's specific
5:08
mutations that are actually driving the cancer forward
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and the reason that we may want to know that is because there's
5:13
sometimes there's drugs that we could use specifically
5:16
for those situations or there's clinical trials
5:19
that you might be eligible for based off of those situations
5:22
so that's the Altera test
5:24
the Empower test is a blood test for hereditary cancers
5:27
so those are used for
5:28
or that's used I should say for patients who
5:31
may be at higher risk because of a family
5:33
history for example
5:34
for certain kinds of cancer that run in families um
5:37
and then our MRD portfolio again molecular
5:40
residual disease and we'll talk about what that is
5:42
is kind of comprised of three different tests
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Signatera Signatera Genome and Latitude
5:49
Signatera and Signatera Genome uh
5:51
require tissue and Latitude is just a blood test so we
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um use different features of of cancers that that are
6:00
um unique to cancers but we can understand
6:02
without actually having a piece of the tumor if that makes sense
6:05
um to track signals uh in the blood
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we'll talk a little bit about
6:09
about more what that means
6:10
um but for the rest of the talk we'll kind of focus
6:12
on the Signatera and Signatera Genome
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um so to design a molecular residual disease test um
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we start with a piece of tissue
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so what we're gonna do is we're gonna either get a piece of the cancer
6:24
from a biopsy or a surgical specimen
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we're gonna take the DNA out of it and we're gonna
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sequence it we can do that in many different ways
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um sometimes we do that
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through what's called an exome sequencing
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sometimes we do that through what's called a genome
6:39
sequencing but the
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important thing to know is that now we have a signature
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hence signatera of the tumor
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at the same time we take DNA
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from a blood sample from the patient
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and we do a sequencing analysis on that
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and then we compare those two sequences
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and the reason we're able to
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use a tool like this is because there's an
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important principle here and that is is that
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cancer genomes
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look very different than the genome in our non cancer
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cells so as a lot of the folks in the audience
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might know cancers um
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kind of accumulate different kinds of mutations
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in their DNA and that's what we find
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we find those mutations that are unique to the cancer
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that aren't present in your non cancer cells
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and then we track those specifically
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and we only need the tissue
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the one time so when we track those mutations
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specifically that are unique to the tumor itself
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we can do that just through a blood draw so tissue
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once and every time we look for these signatures
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it's just a blood draw if you have any questions
7:40
about that you can drop them in the chat
7:42
we should have some time at the end to go through that more
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but that's kind of the general
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principles of how we set up this test we're looking for
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mutations
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in the blood that we know are coming from the tumor
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we've been at this for a long time now actually
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um so this test has been available since 2,019 it's
7:59
it was in development for years and years before that
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lots of very smart people working on this at
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institutions all over the world
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um we now have over actually 145 publications
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out there around this technology we're actually
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responsible for over 90% of all the literature
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uh in this space as it pertains to tissue informed
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commercially available assays all that work has now
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resulted in data that's reported out across
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30,000 patients and 30 different tumor types
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over half of US oncologists have ordered this test
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and that represents testing across
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over 300,000 patients as part of clinical practice
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so the test is available
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we have a very good team that helps support testing
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in the clinic to make sure that the tissue
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is acquired and the
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results are returned and if there's any questions
8:45
about interpretation
8:47
physicians and patients have a lot of support
8:50
you're probably thinking about payment
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um we do have Medicare coverages
8:54
rolling in as you may or may not know you typically
8:56
have to apply for uh Medicare coverage by indication
9:00
so you can't kind of do it once you have to do it over and over and over
9:03
again
9:04
at least in the case of these types of diagnostics
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so that's a long process but we um
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commit a lot of time and energy to that so that we could get
9:12
different indications
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approved for reimbursement by Medicare
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it's a very similar process for private
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insurance as well private insurance will typically
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follow Medicare's lead um so over time
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more and more of these approvals come through
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you could see the ones that we have already
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we have a bunch more we're working on every day now
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but I do like to note that we actually don't balance
9:33
bill patients so as of you know now
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there's no financial toxicity to testing
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so you shouldn't get a bill even if you um
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aren't covered by Medicare
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if you have private insurance
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and they decline to cover
9:44
we don't send the balance
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to you that's how it is today
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um
9:50
all right so how do we interpret the results
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um so what you're seeing here are called
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Kaplan-Meier curves uh KMs
9:56
for short you may have heard of these or seen these
9:59
um and you're looking at two populations of patients
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that are separated based off of if our test
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is positive or if our test is negative
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you could see those two lines
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do not look alike right they're different colors
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they're also very far apart
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and so what we're looking here
10:12
is that the probability of being free of relapse
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relapse free survival
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over time based off of a result with our test
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so you could see if you're CT DNA negative
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that's MRD CT DNA negative our test is negative
10:28
you're on that green line
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right you have a higher probability
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of being free of disease
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compared to if you're on the blue line
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which is if you're CT DNA positive
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so a lot of you may be familiar with biomarkers
10:39
what we call prognostic biomarkers
10:42
this is very powerful prognostic biomarker
10:45
right we could tell um
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very early and and very accurately through this test
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uh if patients positive
10:53
they have a very high risk of having persistent disease
10:55
that will eventually be able to see on a scan
10:58
versus negative they're much less likely to do so
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doesn't mean they never will no test is perfect ours
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included um however
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you have you could see the the likelihoods here uh
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across different tumor types of being free of disease
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or not free of disease over time
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can you make treatment decisions
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around that that's the big question
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prognostic information is great can we do anything
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about it um it's a much harder question it takes
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a lot of patience
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and a lot of time to answer that question
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and that's what we're actively
11:26
working on now that's pretty much what my job boils
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down to is finding out can we do that
11:31
so I'm showing you data across a few different
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studies here in a few different cancer types
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we'll start across the top with colorectal cancer
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um so we published this in a really big journal called
11:41
Nature Medicine in 2024 and what you're seeing
11:44
here again there's those km curves
11:46
you're seeing that if you're positive by our test
11:49
after surgery
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it was better to get chemotherapy right the blue line
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has a better freedom of disease
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result than the red line
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so if you're positive you wanted to get
12:01
chemotherapy after surgery it improved your outcome
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in terms of your freedom from recurrence
12:07
if you were negative you'll notice those lines
12:09
don't look like the lines in the positive
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group right they're right on top of each other
12:14
what that means is there was no difference
12:16
so if you were negative by CT DNA
12:18
and you got adjuvant chemotherapy it actually
12:21
didn't change your outcome in terms of your disease
12:23
free survival so very exciting right this suggests
12:25
you could potentially use a molecular test
12:28
to make decisions about chemotherapy after surgery
12:31
in colorectal cancer as you can imagine
12:33
this is the type of thing we have to do over and over and over
12:36
again
12:37
before it becomes the norm but certainly very exciting
12:40
data here and and we hope what the future looks like
12:43
similar data in the blue box
12:45
there that's now looking at adding
12:47
another drug to the usual regimen of chemotherapy
12:49
called celecoxib you guys may have heard of that
12:53
you could see
12:53
again we have two different sets of lines
12:56
the lines on the bottom are far apart from one another
12:58
those are the patients who are positive after surgery
13:01
the lines at the top are right on top of each other
13:03
telling you there's no difference between those patients
13:05
with um the drug or a placebo
13:08
and those are the negative patients
13:10
so again selecting patients by
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CT DNA to to predict who will benefit uh
13:15
from an intervention in this case
13:17
the addition of celecoxib the standard
13:19
adjuvant chemotherapy adjuvant meaning after surgery
13:22
and then again looking at the bottom um uh
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charts here now we're looking at um
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urothelial carcinoma
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kind of commonly collectively called
13:31
muscle invasive bladder cancer very similar idea
13:34
the curves at the bottom are the positive patients
13:37
the curves
13:38
at the top that are kind of shaded out are negative
13:40
patients you can see the negative patients
13:42
those curves are right on top of each other
13:44
telling you there's no difference between
13:46
um getting a drug or not getting a drug
13:48
the curves on the bottom are the positive patients
13:50
and you see those are separated right you can clearly
13:53
see at the bottom those curves do not
13:55
sit on top of each other
13:56
meaning there's a difference there
13:58
in this case that difference was
13:59
significant from a statistical perspective
14:02
and that means that we were able to give patients
14:04
a repossitive drug
14:05
in this case Atezolizumab and again improve their
14:08
outcome
14:09
in this time we're showing both freedom from disease
14:11
and overall survival
14:12
meaning you were more likely to just be alive in general
14:15
if you were positive and got the drug versus positive
14:18
and didn't get the drug
14:20
um
14:21
last slide on the same point um
14:23
we kind of confirm this um actually in the last year
14:28
um and published this result in a big journal
14:31
you've probably heard of the New England Journal of medicine
14:33
uh showing that you could prospectively
14:35
meaning ahead of time pick patients
14:37
who stood to benefit from in this case
14:39
Atezolizumab after surgery for bladder cancer
14:43
and this resulted just this week in a positive FDA
14:46
approval for
14:47
this test as what they call a companion diagnostic
14:50
for muscle invasive bladder cancer so that means now
14:53
you could use this test officially to select who
14:56
stands the benefit from this drug Atezolizumab
14:59
after they've had surgery for their bladder cancer
15:01
so very exciting
15:02
and I hope this gives you kind of an idea um
15:05
of of where the company's
15:06
headed and the kind of things that we're working on
15:09
moving into melanoma um this is all comers
15:12
all different kinds of melanoma we recently
15:14
published this um
15:15
again we're we're looking at those km curves
15:17
you can see we're looking at um
15:19
recurrence free survival
15:21
again the proportion of patients
15:23
um who are likely to be free of disease over time
15:25
based off of being CTNA negative or positive
15:29
this is looking at
15:31
melanoma patients after resection stages 1 through 3 b
15:35
so again you want to see that wide separation
15:37
of those two different groups and we see that here
15:40
very powerful biomarker
15:41
what this tells you is that if you've had surgery for melanoma
15:45
and you're found to be positive by Signatera
15:48
and nothing is done
15:49
you're much more likely to have a recurrence
15:51
that's what this data suggests
15:53
right in front of us here and so can we leverage
15:56
that to help us think about surveillance
15:59
and treatment decisions in a more personalized
16:01
way that's the kind of the question
16:04
um one thing you'll see over and over again is that
16:07
you know and doctors Montazeri and Doctor
16:09
Ma will tell you
16:10
as doctors we use a lot of different things to
16:14
think about your risk of recurrence
16:17
classically we look at the path report
16:19
and the features of the tumor
16:21
to make these risk decisions and we we base
16:24
our recommendations for
16:25
therapy after surgery or after radiation
16:29
in many ways on
16:30
the the nature of the tumor and all these special
16:33
features of the tumor that we're interested in
16:35
what we're finding out is that your status
16:37
with our test is the most powerful predictor
16:40
when you compare them to the things we classically use
16:43
so you could imagine this list could be a lot longer
16:46
right we could have we think about a lot of stuff
16:48
but in this particular case
16:50
compared to these other things that we looked at
16:53
CT DNA was the most powerful predictor of outcome
16:58
compared to your stage sex and mitotic rate
17:02
um this is actually some data from Doctor Ma
17:05
um this is melanoma data which now includes
17:08
a subset of patients with uveal melanoma specifically
17:11
um and what we're looking here is the change
17:13
in the value of the circulating tumor DNA MRD test
17:17
and how that correlates with what we call disease
17:20
control and objective response so you see three
17:24
colors at the bottom progressive disease
17:28
disease control and objective response
17:31
as you could probably guess progressive disease is
17:35
is the least favorable of those things
17:37
and what we're seeing here is that the
17:39
the change in the amount of CT DNA in the blood
17:42
can help us predict which bucket you're gonna fall in
17:46
right
17:46
so you could see the median change in quantitative
17:49
value by those three categories
17:51
so patients with disease control had a median
17:53
decrease of 82% in their quantitative value of CT
17:56
DNA in the face of therapy
17:58
88.3% for objective response
18:02
and then the complete opposite right a rise
18:06
in progressive patients so if the CT DNA is going up
18:10
this would suggest you have a much
18:11
greater chance of having disease progression
18:14
can we use that information
18:15
does it add any advantage to your care
18:18
can we tell that you're gonna progress
18:20
before you progress and importantly
18:22
can we leverage that information to prevent
18:24
that or delay that
18:26
can we improve your outcome using this information
18:28
that's the job in front of us
18:30
so CT DNA decreasers had 30 times higher odds of disease
18:33
control
18:35
and 23 times higher odds of objective response
18:38
um very similar data
18:40
presented in a different way there's those good old kms
18:42
again um
18:43
now we're looking at progression
18:45
free survival and overall survival
18:47
we're asking about um
18:48
the change in the quantitative value of CT
18:50
DNA after one cycle of
18:52
a class of drugs called immune checkpoint inhibitors
18:55
you've probably
18:56
heard of these and are familiar with these
18:58
we're looking at patients who went down
19:00
after a dose versus patients that went up
19:03
and again you see separation in the curves
19:05
here for progression free survival
19:07
and overall survival
19:09
and then importantly
19:11
one step further we asked about clearing your CT DNA
19:15
and what you really wanna see is that you start
19:17
from some quantitative value you start on a treatment
19:21
you go down right away and then shortly thereafter
19:24
it goes
19:25
away we can't see it at all in the blood anymore
19:27
and that's what you're seeing
19:28
here so you have three groups of patients
19:31
green patients had clearance of CT DNA on therapy
19:34
blue patients had a decrease
19:36
but didn't make it to clear
19:38
and then orange patients had a rise
19:40
better to be towards the top of the graph
19:42
than the bottom it means your probability of being
19:45
alive and free of disease is better the higher you are
19:48
and you can see we have wide separation
19:50
of the clearance curve
19:52
from those patients who didn't clear CT DNA
19:55
so you can imagine we have now
19:57
potentially a real time biomarker to adjudicate
20:00
response prediction
20:02
based off of kinetic change very early on therapy
20:06
right so we hope the future
20:07
looks like we don't have to sit
20:08
around and wait for scans
20:10
to show us what's going on we could very very early
20:13
through a blood test
20:14
understand if the current medications
20:16
that you've been prescribed
20:18
are gonna get you on the green curve
20:20
right if not can we do anything
20:21
about that can we change things can we intensify things
20:25
um all all in the name of improving the outcome
20:29
so I know that's a lot of information
20:30
I tried not to be too crazy technical with it
20:33
uh if you have questions please we can go deeper
20:36
um but at this point I will hand it off
20:38
to doctors Montazeri and Ma um
20:41
to talk about their experience with the testing
20:43
awesome thank you so
20:45
okay who wants to go first
20:48
I think Doctor Ma has some cool slides okay Doctor
20:52
Ma we're gonna put you on the spot
20:53
easier to follow than Doctor Krainock very
20:56
academic talk no it was great very fascinating
21:01
yeah no I appreciate Doctor Krainock
21:05
yeah going through a really wonderful overview
21:07
of CT DNA and some of the amazing data
21:09
you know that we obviously see in
21:12
you know both melanoma but other
21:13
cancer types so as you all know it's
21:15
such an evolving field right um
21:18
and so you know I do have a a few slides
21:21
I'd be happy to sort of share with the audience
21:23
just to kind of give you all a little bit of like a real world
21:25
perspective of like how
21:27
me as a medical oncologist is sort of using this test
21:29
in in real practice
21:32
and and certainly
21:32
the two examples I'll I'll share are patients
21:35
with uveal melanoma
21:38
so I'll go ahead and share my screen
21:40
and hopefully you all can see my screen okay
21:44
yeah you're good you're full screen excellent thank you
21:48
so um you know just to share a couple of examples
21:50
this first case
21:51
is actually a gentleman that I cared for um in his 70s
21:55
who was diagnosed with a right
21:56
eye choroidal melanoma that was class 2 and prame
21:59
positive
22:00
and was treated with brachytherapy back in 2020
22:04
and so unfortunately
22:05
you know during surveillance because um
22:08
he was considered to be high risk
22:10
he actually ended up developing
22:11
new liver metastases in January 2,024
22:15
um you know he was um HLA tested and was negative but
22:19
after sort of reviewing a variety of different options
22:22
available um he actually ended up um opting
22:25
for treatment
22:26
with melphalan percutaneous hepatic perfusion therapy
22:30
um and as some of you in the audience
22:31
may know it's also known as Hepzato
22:33
as the commercial name so you know um
22:37
what was really phenomenal
22:38
about his treatment was he actually did very well
22:41
with therapy you know this uh screen
22:44
here to the left is actually an image of his belly
22:47
and what you can see there
22:49
with that particularly yellow
22:50
arrow it's actually pointing to a pretty large
22:53
liver tumor that's his melanoma liver metastasis
22:57
it measured about 7 to 8 centimeters in size
23:01
and after about one treatment of melphalan
23:04
PHP or Hepzato um you can kind of see that the tumor
23:07
shrunk by almost about 50%
23:09
and so as you can kind of imagine um in my practice
23:13
what I have typically
23:14
been doing and this is something I actually
23:16
offer to my patients is
23:18
you know would you like to be monitored
23:20
with circulating tumor DNA
23:22
not necessarily by itself
23:24
but as sort of a a compliment
23:26
as a way to kind of see how well
23:29
you're benefiting from treatment um and so the patient
23:32
actually opted to to participate in it and and as
23:35
Doctor Krainock has sort of mentioned
23:37
what we did was we submitted um
23:39
one of his liver tumor biopsies
23:41
to actually build the personalized assay
23:44
and we were actually able to assess a baseline
23:47
circulating tumor DNA before he was started with
23:50
um Hepzato so you can see here this little
23:53
a top blue dot here to the far left and we serially
23:57
meaning we checked his CT
23:59
DNA level throughout the course of treatment
24:01
and you can see here just like what we saw on his CT
24:04
scan his CT DNA level actually downtrended quite
24:08
beautifully well so you know a very nice complimentary
24:12
test to kind of how he is doing
24:14
with treatment and a good way to monitor his progress
24:18
now of course you know during the course of therapy
24:21
you know as he was getting um
24:23
additional cycles of melphalan PHP
24:27
you know we noticed that he's obviously
24:29
continuing to do great
24:30
I mean you can look here in the far right
24:33
CT scan image here his tumor
24:36
shrunk quite nicely and this was after three cycles
24:39
of melphalan a PHP and so the tumor
24:43
continues to shrink so he's obviously doing
24:46
phenomenally well but what was really interesting
24:49
especially in this particular case example was using
24:52
circulating tumor DNA as a monitoring tool
24:55
you'll sort of notice in particular
24:57
that as we're monitoring the amount of circulating
24:59
tumor DNA the levels were starting to rise
25:02
you know with subsequent cycles of treatment
25:05
and I'm like well why is that the case right
25:09
especially if the tumor is
25:11
continuing to shrink in the liver and
25:13
mind you and as a reminder
25:15
uh his disease was really just confined to the liver
25:18
so
25:19
you know how did I sort of use this sort of information
25:22
right as a medical oncologist
25:23
who is certainly wondering why is the CT
25:26
DNA level rising you know where in particular
25:29
could the CT DNA level be coming from
25:32
particularly if his tumor is
25:34
continuing to do incredibly well in terms of shrinkage
25:37
from the therapy and so what this ultimately
25:40
led to was it prompted
25:41
me to actually do some additional imaging
25:44
so it actually
25:45
prompted me to sort of adjust a different modality
25:48
in terms of how I can assess what's going on
25:51
and so what I ended up doing was getting a pet CT scan
25:54
and what I had discovered
25:55
was that he was actually found to have new bone
25:58
metastasis and so that would not otherwise
26:01
have been picked up that well
26:02
with some of the standard imaging
26:04
that I was using for him such as the MRI and CT
26:07
and so you can kind of see here
26:09
using CT DNA can actually be a very powerful tool
26:13
to not only help with monitoring treatment
26:15
response but it actually can help me as a provider
26:18
really prompts me to do um earlier assessments
26:22
with scans particularly if a CT DNA level
26:25
is rising during the midst of therapy
26:28
and in this particular case example
26:29
change in an image modality especially
26:32
if the standard of what I'm using is not sufficient
26:35
enough to capture
26:36
what's going on with the disease status in the body
26:40
so that was just one
26:42
interesting case example another one is a case
26:46
of a patient who I also cared for she's in her 70s
26:49
and was diagnosed with a right eye choroidal melanoma
26:53
she had a class 1 prame
26:54
positive tumor and was treated with enucleation
26:57
back in 2016
26:59
um she actually unfortunately
27:01
six years later developed
27:03
long liver and pancreas metastases
27:07
um she was HLA-02:01 positive but um
27:11
around the time when she developed metastatic disease
27:14
a really main feasible options were
27:16
immune checkpoint inhibitors as Doctor Krainock
27:18
mentioned it's a type of a immunotherapy treatment
27:22
so she was treated with
27:24
ipilimumab and nivolumab but unfortunately um her tumor
27:28
actually progressed on this particular therapy
27:31
and unfortunately around the time that she progressed
27:34
we now had the availability
27:35
of Tebentafusp also known as
27:38
uh Kimmtrak is the commercial name
27:40
um as an available option for her
27:43
and so what we actually ended up doing
27:44
for her was we actually did a combined approach
27:47
therapy so we did both radiation therapy as well as
27:51
Tebentafusp as her treatment so
27:55
what was really great about her particular case
27:58
was you know when we did the radiation therapy
28:01
um as well as the Tebentafusp we actually checked
28:04
the level after she had sort of started both therapies
28:07
we actually did not get a baseline but
28:10
what's pretty awesome about this particular
28:12
case was that she actually had an undetectable
28:15
circulating tumor DNA so
28:17
in some ways it gave me a level of confidence
28:20
knowing that you know she probably or most likely had
28:23
a very low burden of disease or maybe
28:26
we might be sort of getting to a point where you know she has
28:28
more so just microscopic disease
28:30
that we just can't detect
28:31
by circulating tumor DNA testing now of course
28:36
how have I been monitoring her on treatment well
28:39
I've been getting pet scans
28:40
on her so what I've been doing is getting a pet
28:43
scan on her every two months
28:45
while she was on Tebentafusp and what's very
28:48
interesting as you can see here is that the arrow
28:51
is actually pointing to an area that's very hot um
28:55
suspected to be an area that um
28:57
her melanoma had spread to in this case her pancreas
29:02
now you might be sort of wondering
29:04
whoa why is it lighting up right well
29:08
we know that her melanoma had spread to the pancreas
29:11
but because we had delivered radiation
29:13
therapy to that site
29:15
it's very probable that this ongoing inflammation
29:18
may actually be
29:20
um just the residual inflammation from her
29:23
radiation therapy
29:24
and not necessarily from active cancer and so
29:29
the CT DNA blood testing sort of give us
29:32
gives us sort of that level of sort of reassurance
29:35
for her and as you can see here as I
29:38
continue to get pet CT scans we still see that her CT
29:42
DNA levels that accompany the scans continue to remain
29:46
undetectable so to some extent
29:48
it gives me as well as the patients a relatively
29:51
high level of confidence
29:52
that the disease remains under control
29:54
while I continue Tebentafusp now after the patient
29:59
has been sort of on treatment for almost two and a half years
30:03
um what sort of happened was we unfortunately
30:05
started to detect
30:07
circulating tumor DNA positivity in her blood
30:10
and of course we got a pet scan sort of
30:13
around that time and
30:14
again two and a half years of therapy
30:17
and interestingly enough I cannot
30:20
find any sort of new signals
30:22
or any new abnormalities anywhere and again
30:26
this arrow points to that area of inflammation
30:28
around her pancreas
30:30
and so what did this sort of information
30:33
help me with particularly with a positive
30:35
CT DNA test was well I gotta go searching
30:38
for where the heck this is coming
30:40
from so that I could potentially think about
30:42
intervening with a new level or new line of therapy
30:46
and so what I ended up doing
30:47
was we did some additional testing and had found
30:51
that she was found to have a cardiac or heart
30:54
metastases that would not otherwise be easily detected
30:58
by a pet scan generally speaking pet scans
31:01
tend to light up pretty well on the heart
31:03
because it's a very metabolically active organ and so
31:07
really how what did I use the CT
31:09
DNA testing in this particular case was
31:12
it really prompted me
31:13
again to also think about a different imaging modality
31:16
and it gave me a good idea of what may be sort of a
31:20
potentially false positive or abnormal
31:23
uptake in a pet scan that would otherwise
31:26
look like cancer
31:26
but is unlikely the case because the DNA's levels
31:29
negative it allowed me to get confidence about okay
31:33
if it becomes
31:34
positive that's where we need to think about
31:36
is there other disease elsewhere and of course
31:39
you know with this positive information
31:41
here it sort of aided me in the assessment of
31:44
how the patient was doing with her
31:46
current line of therapy specifically with Tebentafusp
31:48
so really
31:50
long story short is you know I've been using
31:52
CT DNA as a tool to complement imaging
31:55
but also using it in a way to help me identify ways to
31:59
change imaging
32:00
but also think about next lines of therapy so
32:05
hopefully that kind of gives um
32:06
a little bit of a perspective
32:07
of you know how I've been using this test
32:09
but um but yeah I would love to see and hear
32:12
um how Doctor Kam
32:14
Montazeri has been using this test in her practice
32:17
as well fascinating slides
32:19
thank you so much thanks to both of you yeah similarly
32:22
um this has been very helpful in
32:25
some of the challenging
32:26
cases especially as you mentioned with
32:28
Tebentafusp because um
32:31
as uh many people may be aware it has a very
32:35
low chance of showing radiographic response
32:38
and most of the patients
32:39
that actually do benefit from that they have um
32:43
the lesions
32:43
look bigger on the next scan that the patients have
32:46
initially um
32:48
it was a little hard to you know convince yourself
32:52
as a specialist and also convince others to
32:54
continue the treatment
32:55
while you see lesions getting bigger
32:57
and now this does not apply to everyone
33:00
on the treatment but um there was also a similar um
33:05
a test similarly to what Doctor
33:07
Ma showed you guys um the um
33:10
um basically investigators um had collected
33:14
blood samples from the patients
33:15
that were treated from the uh
33:17
face on the phase 3 study of Tebentafusp
33:20
and they looked at um
33:22
the CT DNA levels of these patients and um
33:26
interestingly those patients
33:28
that had negative CT DNA or they had
33:31
uh cleared out um their CT DNA's um
33:34
early on during the treatment they did better
33:37
and those patients that had um
33:40
basically
33:40
reduction any type of reduction in their CT DNA levels
33:44
they actually
33:44
continue to benefit from Tebentafusp despite um
33:48
radiographic disease progression
33:50
so in some ways it is a very helpful tool if um
33:54
you don't have um
33:55
a better way of um assessing response to disease uh
34:00
during the treatment
34:01
it has actually happened to me as well that um
34:04
because of as per the guidelines and also per um
34:09
the natural history of uveal
34:11
melanoma we worry more about the liver and um
34:14
for active surveillance of the patients
34:16
most of us use some sort of liver imaging
34:19
usually an MRI of the liver which is very precise and
34:24
sometimes
34:25
depending on how much you're worried that somebody
34:27
may have disease recurrence you also use CT
34:30
of CT scan of the chest to also monitor the rest of
34:34
and the rest half of the body
34:35
but sometimes you can't see
34:37
some subtle changes in the bone or somewhere else
34:40
and um I had a similar case that um
34:43
actually one of the participants asked how we can um
34:48
develop this CT DNA assay if the patient had um
34:51
hasn't had any biopsy or disease progression
34:54
if somebody has had um
34:56
enucleation in the past you can use that tumor um
34:59
as basically an
35:02
a tissue to make in the assay
35:05
or the tissue template
35:07
so that's what we had done for that patient of mine
35:11
and yes we saw a significant rise in CT DNA
35:15
and our detective work began and with
35:19
the pet scan we found a lot of very small diffused
35:23
lesions on the bones and um the
35:28
then we started the treatment which probably would have
35:33
not been as successful if we had started
35:35
the treatment later
35:36
sometimes unfortunately we don't have these tools
35:38
because if you have a fine needle
35:40
aspiration biopsy from your
35:43
primary lesion
35:44
unfortunately that's too small at least with the
35:47
technology these days to make a template um
35:51
so there is no
35:52
close to perfect assay in that setting yet
35:57
however this is a helpful tool the other way
36:00
that we have used it is that sometimes
36:03
when a patient has had disease progression
36:07
on a certain treatment
36:10
based on you know where the
36:12
growing lesion is and how many growing lesions are
36:15
instead of taking
36:18
instead of changing the whole systemic therapy we
36:22
decide to add some local therapy
36:24
either radiation therapy or
36:26
liver directed therapy or cryoablation depending on
36:30
where and how many lesions we have and um
36:34
there was also some evidence of um
36:37
additional benefit to um
36:39
continuing the systemic therapy in a disease
36:42
that has very few effective treatment
36:44
options and adding some treatment and you can
36:46
see actually that CT DNA pattern uh
36:49
dropping and giving reassurance to both
36:52
us as clinicians and also the patient
36:55
awesome thank you guys both so much and Doctor
36:57
Krainock thank you so much for your presentation as well
37:00
um we are getting inundated with questions
37:01
from the audience so this is great
37:03
but I'm gonna run through the chat first because we
37:06
started to address this and I wanted to just make sure we clearly
37:08
answer um can this test like the Signatera test um
37:12
a tumor informed
37:13
CT DNA be done from the primary eye tumor
37:16
or just from metastases
37:18
what are you guys seeing and I know Doctor Montazeri
37:20
you kind of touched on this a little bit
37:22
yeah it depends on how much and then Doctor Krainock is
37:24
the best person we have
37:26
actually the actual person that we depend on
37:29
to make the um test but um
37:32
it depends on how much tissue we have
37:34
um with just a small needle
37:36
biopsy there's not gonna be enough tissue to make that
37:39
um
37:40
if you had a surgery to remove um
37:44
the actual tumor meaning enucleation or
37:47
from the metastatic tissue
37:49
most of the time it's possible to make that assay
37:52
yeah uveals I mean as everybody in this crowd knows
37:55
tough because there's not a lot of tissue to go around
37:57
um we're always making progress
38:00
on the input material needed to design so you know
38:04
every year it seems like we can do it with less and less
38:08
um in other cancers you know
38:11
we have designed successfully
38:12
from fine needle aspirates
38:15
even of metastatic lymph nodes where you know
38:18
you may not have a ton of cancer cells there um
38:21
so we are like I said tumor informed
38:23
for Signatera so we do need some
38:25
we will try with very little and we will have
38:28
success but as Doctor Montazeri has alluded to
38:32
the more we get
38:34
to design from the better the chances we could design
38:37
um
38:38
we do have that latitude test that is tumor naive
38:42
meaning we don't need any tumor tissue at all
38:44
um so that may be something that is uh valuable for uh
38:49
you guys uh providers and patients in the next uh
38:53
you know couple of years as we roll out our tissue
38:55
naive test
38:57
um so I would say
38:58
we we will try from pretty much anything
39:01
um and and we are good at small input volumes
39:06
um and getting better
39:07
and but we do fail to design sometimes
39:11
and uveal's one of those words especially tricky
39:13
because there's not a lot of tissue to go
39:14
around that's absolutely true yeah for sure
39:17
um this look
39:18
this question is also kind of pertaining to the
39:21
obtaining a sample using a sample
39:23
this person is asking if if you had a Caris test done
39:26
um
39:27
so like that's typically
39:29
the liver biopsy I think for those of you guys listening who don't know
39:32
um
39:32
if you have the Caris test done can they use the Caris
39:35
existing test
39:36
for the initial sequencing of the Signatera
39:39
it's a great question super insightful question uh
39:41
unfortunately no haha um so
39:44
so we have to do it it's a great it's a great
39:48
idea right cause there's not a lot of tissue to go around
39:50
um
39:52
but the way these labs all all labs are are um
39:57
set up and regulated
39:58
right it's very specific you have to follow very specific
40:01
standard operating procedures
40:03
to stay within compliance of regulatory bodies and
40:07
uh quality assurance metrics
40:09
and so the short answer is we we cannot mix sequencing
40:14
amongst companies even amongst academic collaborators
40:20
without going through super super specific and strict
40:23
protocol developments um so unfortunately
40:26
whoever asked that question
40:28
that's a super insightful question um
40:31
and you really understand the concepts
40:33
here but unfortunately no we can't do that
40:37
maybe to also follow up on that as well
40:40
you know because to to develop a Signatera
40:43
personalized assay you have to have you know
40:46
sufficient tissue to build that assay and so you know
40:50
I really find that biopsies
40:52
or tumor tissue is just so incredibly valuable
40:54
right cause we can use that information to do
40:57
sequencing in the tumor look for mutations
41:00
that might inform treatment options down the road
41:02
and in this case we can also use it to develop a CT
41:05
DNA assay and so what I often encourage patients
41:09
and even other providers
41:10
to think about is that before you send off that tumor tissue
41:13
for testing
41:15
for whatever reason you know make sure that it
41:17
is there
41:17
enough of it that could potentially be utilized for
41:20
other testing as well
41:22
because I've had and I've run into situations where
41:25
if you submit it for NGS testing there is just not
41:29
enough sufficient tissue to unfortunately do
41:31
Signatera testing for the patient
41:34
one way Natera
41:34
is trying to get around this
41:36
not get around this but tried to um solve this is by
41:41
learning how to do the Altera
41:43
that I showed and the Signatera
41:44
test from the same tissue
41:46
right so we're able to do that with Exome base
41:49
Signatera and Altera
41:50
today and I hope within the year
41:52
we're able to do that with um Signatera genome
41:55
and Altera so then
41:58
you could do what the audience
41:59
participant is suggesting
42:00
right you could take one piece of tissue
42:02
you could get a comprehensive genomic profiling assay
42:06
completed and those results back
42:07
and then as a completely separate test
42:09
from the same piece of tissue
42:11
you could get your Signatera assay
42:14
so within the same company
42:16
or the same
42:17
academic center would have you it's a lot easier to do that type of stuff
42:21
yeah that makes sense and I think you know just from
42:23
from a perspective like thinking about the different
42:25
biopsies and things that we have going on as patients
42:28
most patients
42:29
at the primary tumor stage like with the eye tumor
42:31
are mostly having the Castle Biosciences test um
42:35
which has been proven
42:36
you know to be a really good genomic sequencing
42:38
but it would be really really
42:39
interesting to see if over time we could you know
42:42
start using those needle point uh biopsy
42:44
and if they could just take two samples
42:45
at the needle point biopsy point like when they do
42:47
brachytherapy um like
42:49
doing the plaque and and just basically
42:51
kind of have the providers
42:52
be aware of the like like Doctor
42:54
Ma said like be aware of the kind of
42:56
the range of tests available
42:58
and to try to make sure that you get
43:00
you know as much information as possible
43:02
from that one time that you're biopsying
43:04
yeah no absolutely um
43:08
that that you know
43:09
it's we're always up against this in in
43:12
almost all cancers now right we're getting
43:13
less invasive and we're trying to do more stuff
43:17
so we're able to make diagnoses based off of more
43:20
minimally invasive approaches
43:22
but the list of things that we need to do with that tissue
43:25
gets longer every year which is a good thing
43:28
right it means we're learning
43:29
more about the cancer but um
43:31
it's a conundrum because we're we're trying to do less
43:34
for acquisition
43:35
but we're trying to do more with what we get
43:37
so it's a balance yeah absolutely um okay so let's see
43:43
um
43:44
this I think we've kind of covered this but just to clarify if a patient was treated a few years back and there is no tumor tissue
43:49
to biopsy to make the tumor informed Signatera test
43:53
how can a baseline be established
43:55
I guess my understanding is you can't establish a baseline
43:57
at this at this point for the for the um
44:00
tumor informed test that's right
44:02
yeah for Signatera we couldn't design you a Signatera
44:05
in the near term we may be able to design you a latitude
44:09
okay
44:10
um let's see
44:13
Signatera
44:14
negative like Signatera negative with a positive
44:16
okay so this is an interesting
44:18
thing and I've actually had this happen as a patient
44:19
myself
44:20
for those of you guys listening if you didn't know I'm also a metastatic
44:22
uveal patient um so you know
44:25
this patient is saying what about patients
44:26
who are CT DNA negative
44:28
but have a positive tumor burden in the liver
44:31
like all of them are small less than 8 millimeters
44:33
do we understand why metastatic
44:36
uveal melanoma is kind of like a low shedding tumor
44:39
or like low shedding disease like ultimately
44:41
why why could you see disease on an MRI in the liver
44:44
but not be picking up the residual
44:46
or you know the the Signatera
44:48
yeah it's a great question um
44:51
and I'd love to hear Doctor's Ma and Montazeri's
44:53
thoughts I'll give you you know just briefly it's
44:56
in the setting where we have
44:59
radiographically evident disease
45:02
that's tissue confirmed meaning we know those sub
45:05
with 8 millimeter sub centimeter nodules are
45:09
are cancer right and they're not um
45:13
treatment effect
45:14
or fibrotic change or what have you right
45:17
it's actually better to be negative
45:18
than positive in that scenario
45:20
right because it means that the
45:22
biology at least at the time of the blood draw
45:26
was the biology now was less aggressive
45:29
uh than the same patient who has a positive result
45:33
right because remember we're going
45:35
if we're going in the
45:36
arm and getting a sample of the peripheral blood
45:39
right so for the test to be positive
45:41
that tumor has to be elaborating
45:43
DNA out into your bloodstream
45:46
um and that is typically
45:47
associated with more aggressive behavior
45:49
right it's doing
45:50
things it's turning over it's elaborating
45:52
DNA into the blood
45:53
at sufficient levels for us to detect
45:57
when you have disease
45:58
you could measure and see on a scan
46:00
but that's not the case that usually infers
46:02
that at that time the biology is actually less aggressive
46:05
so it's more indolent so um
46:08
it in a genome world right
46:11
when we're when we're using the genome test now
46:14
I think that scenario would be will be less common
46:17
because I think we'll be able to detect
46:19
those indolent low shedding tumors
46:22
um at even lower levels
46:24
and so if we come back and we talk in a year or two
46:26
I might be saying the same thing
46:29
but now I might be talking about the quantitative
46:31
value of CT DNA being prognostic
46:34
rather than positive or negative
46:36
I hope that makes sense
46:37
and I'd love to hear Doctor's Ma and Montazeri
46:40
yeah I agree you know
46:41
there is a threshold that you can detect the
46:44
basically those copy numbers in the blood and
46:48
with a different technology which is always a trade
46:51
between those sensitivities and how um
46:54
basically
46:55
confident you are that what you're catching is real
46:58
so if you do a deep sequencing you may be able to um
47:02
catch a very small amount of you know DNA
47:06
shedding to the blood
47:07
but that is always a good sign that um the tumors not
47:12
um you know actively growing and replicating
47:15
uh too fast to shed it to the bloodstream
47:18
yeah
47:19
yeah I think um that's a good problem to have yeah
47:23
absolutely I mean it's always good to have like a
47:26
in my opinion
47:27
we know that having a negative or undetectable
47:29
level is is very is very good in terms of prognosis
47:32
but
47:33
you know I've certainly had those types of scenarios
47:35
where we have a scan
47:37
and a biopsy that confirms active disease
47:39
despite a negative CT DNA level
47:42
and you know sort of how I like to describe
47:44
it is you know we we really have a relatively
47:46
low burden of disease that we just cannot
47:49
detect it at that very moment in time
47:52
with the CT DNA assay
47:54
and so that's kind of how I sort of frame
47:56
it you know with patients is yes even though
47:58
we know there's active disease
48:00
but we can't detect it by by blood
48:02
that doesn't mean you don't have cancer right
48:05
you know the other thing I also described and
48:07
something we've also published you know over the past
48:09
year or so is that you know the sensitivity of the test
48:12
you know specifically for melanoma um
48:15
we've Learned that you know depending on the location
48:17
of where the disease is um you may have a higher
48:20
probability of being able to detect it
48:22
and so for example the most common
48:24
areas that we published and Learned from is that if it
48:26
if you have disease in the lung the lymph nodes liver
48:30
um
48:30
there's a higher chance of being able to detect it more so than if the disease
48:34
had essentially popped up in the skin
48:37
or in the muscle or in the brain for example
48:40
so I think melanoma probably has an interesting biology
48:43
where it has the ability to shed
48:45
DNA with better easier detection than other locations
48:49
depending on where it is in the body
48:51
um but as you can imagine
48:53
I think I think this is really a call to action
48:55
to to really enhance the technology to better detect
48:58
you know cancer in the blood
49:00
and it's very interesting to see you know the companies
49:02
like Natera sort of developing and
49:04
and making their test a lot better
49:06
you know transitioning from an Exome
49:08
based to a Gome based type of assay
49:10
so that we can hopefully increase
49:12
that sensitivity and and make it more reliable
49:14
for monitoring
49:16
yeah absolutely
49:18
um so in terms of this monitoring
49:21
and kind of like the use of the test
49:23
one of the questions from our
49:25
a patient Michelle is asking you know I'm currently
49:29
like a a stage
49:31
um or I guess just a high risk tumor profile
49:33
um so probably a class 2 tumor
49:35
or just you know higher probability of progression
49:37
and there's not currently any adjuvant
49:39
therapy that's being offered for my situation um
49:42
I've been told by my oncologist that CT
49:44
DNA wouldn't help
49:45
as there's currently no treatment available anyway
49:48
how could I potentially use this test at my stage
49:52
so I don't know the question if uh um
49:58
this patient
49:59
had enucleation or are they talking about you know a
50:03
um basically
50:06
a um cell free DNA
50:08
panel like a genome sequencing panel without um an
50:11
a tumor tissue
50:13
it depends on that if we are talking about
50:15
Signatera um we can use that um
50:18
in addition to surveillance scans as a method
50:21
um another layer of information basically for um
50:25
surveillance there have been some situations
50:28
that for example
50:29
if you have a standard of care option like Tebentafusp
50:31
the sooner you bet
50:32
you start the treatment you're not gonna lose anything
50:35
if really there is a very small lesion that um
50:38
you know um
50:40
is difficult to biopsy
50:43
and you have proof that there is a disease recurrence
50:47
and um start the treatment
50:50
um on the bright side if you have um
50:54
negative scans and negative CT DNA that's um you know
50:58
another layer to reassure you um that
51:01
there is no evidence that you have cancer recurrence
51:04
but if you don't have that and
51:06
do not worry I'm sure your doctors
51:09
monitoring everything closely
51:12
well and like I mean
51:13
five years ago six years ago we didn't have CT DNA
51:17
as a reliable marker to use as you know like Doctor
51:20
Montazeri said that extra layer of information
51:22
so you know it's not that we don't have surveillance
51:24
available we still have surveillance as patients um
51:27
we still have Doctor Ma Doctor Montazeri
51:29
other oncologists who they're prescribing scans
51:31
like they're doing lab work
51:32
for other um inflammatory markers like
51:36
there's still going to be monitoring done so if CT
51:39
DNA isn't something that can currently be used
51:41
right now because
51:42
the tissue isn't available to make the test
51:44
um that seems like at least in this patient's
51:47
know in this patient's question that's probably
51:49
more of the the case is that there's just not any
51:51
any residual tissue to use
51:53
um and if you don't have that then
51:55
you know waiting on that longitude or Latitude
51:57
test is that what you called it Doctor Krainock
52:00
Latitude Test um that's an option
52:02
you know just keep watching for that to come out um
52:04
keep an eye out in in the Signatera world um
52:07
we have you know
52:09
another question that came in asking about um
52:11
TrilliumBiO and Oncobit who are launching advanced
52:14
uveal melanoma CT DNA testing um called Oncular
52:17
like do we know of like like how many companies
52:21
I guess currently offer
52:22
CT DNA tests and what's the difference between them
52:25
and is if it's okay I want to ask Doctor
52:27
Ma this question
52:28
because we kind of talked about this in our podcast
52:31
and I don't know that we can put a number on it for one
52:34
um
52:35
I don't know that we could say the exact
52:36
number of of companies that have a CT DNA test but um
52:40
Doctor
52:40
Ma do you wanna go ahead and define the difference like
52:43
but I I yeah just yeah go ahead and just share
52:46
what you would like about that and then I'll
52:47
I'll tease some other answers out of you if I need to
52:50
yeah absolutely I mean
52:52
as you guys know I mean I think CT
52:54
DNA is sort of this hot
52:55
new thing that we see in the oncology world and
52:58
we're using this test and it's it's absolutely
53:00
exploding
53:01
in the field of how we use it and what settings
53:03
you know whether it's for treatment monitoring
53:06
for surveillance
53:07
and so you can imagine it's definitely become
53:09
quite a competitive space
53:10
and I know there's a variety of different companies
53:13
um that are developing their own CT DNA testing
53:16
um and so I think you know how I sort of categorize
53:19
you know sort of the two main types of test for CT DNA
53:22
there's the tumor informed
53:24
so just the one you know like Signatera
53:25
where you actually have to go back to the actual tumor
53:28
tissue look at the DNA changes
53:31
and personalize the test for the patient whereas
53:34
another type of CT DNA test is a tumor agnostic
53:37
meaning that you don't necessarily
53:40
need to go back to the patient's tumor tissue
53:42
but you're actually developing a test
53:44
based on what we know the mutation is likely to occur
53:48
because of that specific tumor so for example for uveal
53:53
melanoma we know about 85 to about 90% of the tumors
53:56
are GNA11 positive or GNAQ positive
54:01
and so you can just right off the bat
54:03
just develop a test that specifically
54:05
looks for that mutation in the blood
54:08
so it's another way to do it is
54:10
um the tumor agnostic method is another method to
54:14
monitor you know for CT
54:16
DNA in the blood without relying on tumor tissue
54:19
you know the person who posed that question um
54:23
on the question there about TrilliumBiO or Oncular
54:26
um it is a relatively new test that has recently
54:30
just become my understanding is commercially
54:32
available here in the United States um
54:34
it only just recently
54:36
became available I think this past month and so um
54:39
I'm certain there's a lot of excitement
54:41
and I think many of us in the melanoma
54:44
the uveal melanoma uh community
54:46
are excited to learn a little bit more about it but
54:49
that might be a potential option that
54:51
we may consider for some of our patients and
54:54
my understanding is that Oncular or TrilliumBiO test
54:57
is a tumor agnostic test
55:01
okay awesome uh I do wanna move on
55:03
for time we've got about 10 minutes left
55:05
before we've got a wrap um but just as a you know from
55:09
from an oncology perspective Doctor Ma Doctor Montazeri
55:12
what made you start trusting
55:13
CT DNA enough to use it regularly in your practice
55:16
well so uh first of all
55:20
no there is there is no perfect test
55:22
we don't have any test
55:23
in medicine that has hundred percent
55:26
you know a capability to detect um
55:28
a disease or exonerate that you don't have the disease
55:32
there is always a um chance that you get a
55:36
test that is falsely positive or falsely negative um
55:40
add to um the point that one of um our participants
55:44
mentioned that they have
55:45
a small lesions in the liver that CT DNA
55:48
uh was has been negative it's good it's a good problem
55:52
on the other hand there are some situations
55:54
that we have multiple small lesions that are growing
55:57
and if we rely on the blood test
56:01
solely we may be falsely reassured
56:03
that there is no disease
56:04
or there is no disease progression whereas you can see
56:07
on the scan that actually
56:09
there is evidence of new small lesions every time so
56:13
I I'm happy that there is a very um basically um
56:19
effective and sensitive tool but um
56:21
we have to also be cautious not to
56:23
rely on just one test and um
56:26
we are still in a phase of collecting
56:29
information on how to use CT DNA
56:32
this is not something that has been approved uh
56:35
for this indication um it is great
56:39
that you know it's not a financial
56:41
burden for the patients to get this test
56:43
but we should also always um
56:46
continue to use the methods that have been
56:49
validated based on
56:51
data that has been more available in the future
56:54
I'm sure that you know all of these tests are gonna
56:58
improve even further and until then we should
57:01
make sure that
57:02
we use different methods together not to miss anything
57:07
yeah absolutely yeah Doctor Ma do have anything to add
57:10
no I think Doctor Montesari um
57:13
highlighted very important points
57:14
and I completely agree with her um
57:17
you know CT DNA testing is something I
57:20
again offer to my patients
57:22
um as an optional test at this time right um
57:25
currently the current
57:27
standard for you know surveillance
57:29
as well as treatment monitoring
57:31
continues to be scans right and while it's exciting
57:34
particularly where we're at now with using
57:36
CT DNA testing in the cancer world
57:39
and we've seen you know approvals
57:41
and this reaching the guidelines
57:43
for using as a optional test to compliment imaging um
57:48
we haven't seen so much of that success quite
57:50
yet I think with
57:51
with melanoma and I think part of it is because
57:54
you know we still need some additional studies
57:56
you know prospective studies
57:58
integration into clinical trials so that we know
58:02
can this test be a reliable and accurate marker
58:05
to be informative for physicians as well as patients
58:09
and really inform treatment decisions right
58:11
um but you know for the time being I think this still
58:14
continues to be an area of ongoing exploration
58:17
and how I've been using it
58:18
um has really been to more so complement
58:21
you know the testing that I'm doing so biopsies imaging
58:24
right at the end of the day those are still considered the gold
58:27
standard um but overall
58:29
you know my trust in this particular
58:31
test has really just been you know through experience
58:33
you know um trying this out on patients
58:35
who are willing to participate and having this test
58:38
done
58:39
and making some really interesting observations and
58:42
having patients
58:43
do this gives us an opportunity to publish these
58:45
results and hopefully validate the use of this test
58:47
in real world clinical practice
58:50
yeah I love it um Doctor Krainock what are some of the
58:54
you know maybe just general unanswered questions
58:57
about CT DNA and in regards to uveal
58:59
melanoma that you guys are kind of still trying to figure out
59:02
um
59:02
like I guess like do you guys have a good direction of where you're wanting to go with like something like uveal
59:06
specifically yeah I think um
59:11
the use cases for uveal
59:13
share a lot of commonalities with other use cases
59:16
right we want to know
59:17
um in patients who have undergone definitive therapy
59:20
and are in surveillance
59:22
is there a benefit to using CT DNA
59:25
during that surveillance
59:27
um can we either
59:29
change our approach to surveillance using other tools
59:32
such that we identify
59:33
interveneable disease earlier and more often
59:36
and or can we actually treat on the signal
59:39
and help patients live longer
59:42
um and then in patients who are actively
59:44
being treated for say metastatic disease
59:47
um kind of like I alluded to in the slides
59:50
can we be an early warning system for regimen failure
59:54
and can that early warning system
59:55
serve as a trigger to change things
59:58
um and and can that help patients um
1:00:01
in terms of their progression
1:00:02
free and overall survival
1:00:04
um so I think those are really exciting opportunities
1:00:06
where we think we could help patients
1:00:07
and improve outcomes um
1:00:09
you know uveal melanoma as this group knows is a rare
1:00:12
tumor um so we work with great collaborators like
1:00:16
um doctors Ma and Montazeri to um generate
1:00:20
data in sufficient numbers to to drive
1:00:22
those types of use cases and and drive the adoption
1:00:25
yeah absolutely
1:00:27
and I think that you know on the flip side of one of the things that you said
1:00:30
you know
1:00:31
CT DNA I think Dr Montazeri you mentioned this
1:00:34
CT DNA at least in uveal from what you guys are
1:00:36
are sharing has sometimes been an indication
1:00:39
and I think even Dr Krainock you mentioned this in your presentation
1:00:42
that you know if you're seeing um a good
1:00:45
response to CT DNA even if the imaging is showing
1:00:48
some level of like small disease progression
1:00:50
or something like that that can be a reason to
1:00:52
instead of like jumping off the treatment
1:00:54
that you stay on it a little bit longer and kind of wait it out see what happens
1:00:58
um and I think Dr
1:00:59
Montazeri you mentioned like specifically
1:01:00
around Kimmtrak that sometimes you don't see the correlation in the scans
1:01:03
but you are seeing continued benefit you're seeing
1:01:07
you know that the patient is having a a good
1:01:09
response in the CT DNA
1:01:10
and that benefit just kind of shows up in the scans
1:01:13
later down the road
1:01:16
um okay so I
1:01:17
oh man you guys have so many good questions
1:01:19
I love it but I also haha
1:01:22
I don't have time to cover all of your guys' questions
1:01:24
so I wanna see if we can cover just a couple quick ones
1:01:27
um this is actually I there's two
1:01:30
two questions I wanna combine and I think Doctor
1:01:32
Krainock this is probably more for you but um
1:01:34
is CT DNA as effective at picking up the molecular
1:01:38
molecular residual disease
1:01:39
if you don't have a complete
1:01:41
set of biomarkers from your tumor sample that's
1:01:43
part one of the question and then I'll ask part two in a sec
1:01:47
um it's a great question like if we can't design
1:01:49
against the full complement of mutations
1:01:51
we typically do uh you
1:01:53
I guess the first thing I'll tell you is usually we can
1:01:56
but if we can't um for whatever reason um
1:02:00
we actually have pretty well preserved
1:02:02
sensitivity and specificity
1:02:04
before we really start to drop variants
1:02:06
and and get down to like you know a three quarter full
1:02:09
assay so to speak
1:02:10
we'll start to see drop off at
1:02:12
patient level performance
1:02:13
I don't have a ton of data there
1:02:15
because we can usually do it
1:02:17
um but suffice to say if this if this
1:02:20
individual asking the question already knows
1:02:22
you know that that they can't get a full compliment
1:02:25
typically
1:02:25
performance is fairly well preserved in my experience
1:02:28
until you really get to like
1:02:30
low variants on the panel mm hmm
1:02:33
um what about like failed CT DNA because of low plasma
1:02:38
um what does that mean in terms of
1:02:40
yeah like that's I guess this is a specific situation
1:02:43
I don't know if this is unique to the Signatera
1:02:45
test or just a different CT DNA test
1:02:47
but they've been told that the CT DNA failed
1:02:49
because of low plasma in the blood do you guys anybody
1:02:52
know what that means or do we not really know
1:02:55
I have not heard of that I have not heard of that
1:02:58
all I could think of is that the
1:03:02
volume submitted to
1:03:04
whether it was us or somebody else was insufficient
1:03:07
insufficient plasma so just make sure that the kit
1:03:10
directions
1:03:10
are being followed whatever test you're using
1:03:13
follow the directions for the draw on the kit
1:03:15
and if reach out to the company if they're not clear
1:03:19
yeah and um I've had that happen
1:03:21
before I don't think it was
1:03:22
noted as like it just said no like sufficient
1:03:25
sample size not obtained like please retest
1:03:27
that was that was the message
1:03:28
that I got at least in my in my Natera uh portal uh
1:03:32
this person wants to know when the Latitude testing
1:03:34
becomes available I don't know that you had a specific date
1:03:36
for that yet we we just
1:03:38
in the in the near future hopefully this year
1:03:41
okay hopefully this year so
1:03:42
just you know keep an eye out
1:03:43
I can't guarantee it but hopefully this year
1:03:46
okay um let's see
1:03:49
let's see let's see let's see um
1:03:51
I do want to cover this really fast
1:03:53
just from our doctor's perspective
1:03:56
okay we know that there's you know this kind of
1:03:58
scanxiety that patients
1:03:59
go through that like extra layer of anxiety
1:04:01
uh anxiety related to having scans having your MRIs
1:04:05
you know ultrasound whatever layer of modality
1:04:07
that you're having for surveillance um
1:04:09
Doctor Montazeri Doctor
1:04:10
Ma how are you guys seeing patients
1:04:12
kind of emotionally cope with the variability
1:04:14
right the roller coaster that sometimes CT
1:04:16
DNA can look like as they're as you're using the test
1:04:19
more regularly
1:04:20
that's a great question Danet um and so
1:04:23
you know over the years I've Learned
1:04:25
you know especially as I'm asking
1:04:27
patients if they want to undergo CT DNA monitoring
1:04:30
and that we know sort of the risks and benefits right
1:04:33
as we're waiting
1:04:34
for this test to be you know further validated
1:04:36
be integrated into guidelines
1:04:38
you know it still remains an area of ongoing
1:04:41
you know exploration in its use right
1:04:43
and so what I often
1:04:44
say from time to time especially with these
1:04:46
results is that you know sometimes they
1:04:48
you have to take them
1:04:49
a little bit with a grain of salt you know
1:04:51
say for example
1:04:52
we've ran into the example where there's active tumor
1:04:55
in the body on scans and biopsy but it's negative right
1:04:59
and so those scenarios
1:05:00
can come up as we're utilizing and
1:05:02
integrating this test into clinical practice but
1:05:05
what most
1:05:05
important thing I also mentioned is you know these
1:05:07
these results can sometimes
1:05:09
cause a great deal of anxiety you know kind of waiting
1:05:11
for that result to come back
1:05:13
you know about a week or so later um
1:05:15
can provoke a lot of worry for patients
1:05:18
and that's something I actually discuss
1:05:19
quite a bit with patients when we
1:05:21
decide whether to integrate the test into monitoring um
1:05:24
but long story
1:05:25
short is I think after discussing a lot of that I think most patients
1:05:28
would rather know rather than not you know
1:05:31
as I mentioned
1:05:32
it is intended to be used as a complementary test
1:05:35
and we still need to
1:05:37
again be very cautious about you know how we
1:05:39
interpret it because
1:05:40
again it is still an area of ongoing research
1:05:44
yeah absolutely Doctor Montazeri
1:05:47
yeah I totally agree with what Doctor Ma said um
1:05:50
it is like any test you know
1:05:53
having a good result is reassuring
1:05:56
waiting for that brings anxiety you know
1:05:59
living between the two scans
1:06:00
and also dealing with the um
1:06:03
non desirable results um
1:06:07
it's there is no easy way to reassure
1:06:10
one person who's going through this um
1:06:13
it is different of course I'm sure for the patients
1:06:15
than for um
1:06:17
the the healthcare providers for the doctors uh
1:06:20
one thing that I reassure
1:06:21
them is that you know we are monitoring
1:06:24
things as closely as possible so
1:06:27
we are doing whatever that needs to be done
1:06:30
for this cancer
1:06:31
I don't want this to take over your life I don't want you to
1:06:34
you know just um
1:06:37
sit at home and
1:06:39
just think about what's gonna happen on the scan
1:06:41
or what am I gonna do there is nothing else that you need to do other than
1:06:45
showing up to your appointments
1:06:46
and we are a team and we can figure this out together
1:06:51
absolutely I love that um okay well
1:06:53
I think there's one last technical question um
1:06:57
and I think that this is the answer to this I can guess
1:07:00
um but I'm gonna let Doctor Krainock and Doctor
1:07:02
Ma Doctor Montazeri kind of weigh in here um
1:07:05
if you're having CT
1:07:06
DNA done and you're seeing
1:07:07
like like kind of a low number right like on the scale
1:07:10
like I know sometimes the results scale um Doctor
1:07:13
Ma the slides that you showed you had one CT
1:07:15
DNA test where it showed like a range from zero to 100
1:07:18
and you had results in there that
1:07:20
I don't know quite what it was measuring but
1:07:22
um but like I've seen patients
1:07:24
with CT DNA that measures you know 150
1:07:27
and then I've also seen patients
1:07:28
that measure like 1.5 or point zero three
1:07:33
do you guys have kind of a a way of determining
1:07:36
low tumor burden
1:07:37
using the CT
1:07:38
DNA test or is that still kind of like an evolving
1:07:41
research to answer um
1:07:43
Doctor Krainock I don't know if you've got any
1:07:45
insights there
1:07:46
um
1:07:49
so I kind of set the scale in my mind per patient
1:07:54
uh huh so I let the patient kind of
1:07:57
um is it high for them or low for them right so like
1:08:00
you know 80s high and a thousands high I've seen both
1:08:04
right so but it but not commonly so I
1:08:07
I think of it within the patient I don't know across
1:08:09
patients certainly in melanoma if we have
1:08:11
enough data to stratify what's high and what's low
1:08:14
like as a group as a categorical
1:08:17
um so I think about it more uh within the patient
1:08:21
yeah and I'm seeing Doctor Ma nodding
1:08:24
yeah I mean I would say just based on observations
1:08:27
that I've seen having ordered this test you know um
1:08:30
on patients in a in a variety of different settings
1:08:32
and I think um
1:08:34
of course this is something we need to
1:08:35
continue to publish on is
1:08:37
um I I have seen you know some correlation between
1:08:41
um higher disease burden with a
1:08:43
relatively higher measurement of circulating tumor DNA
1:08:47
um whereas you know lower disease burden
1:08:49
more likely to have lower or even
1:08:51
you know sort of undetectable
1:08:53
you know I I don't know if you
1:08:54
remember Danet when we did our
1:08:56
webinar where we talked about like
1:08:58
the analogy of CT DNA right I kind of call it like
1:09:02
poop right the analogy of calling CT DNA is poop um
1:09:06
it's basically
1:09:07
a byproduct that you know essentially you can
1:09:09
measure right a waste
1:09:10
product you can measure in the blood
1:09:12
and so if you have a great deal of active or live tumor
1:09:15
you're able to measure that much more reliably
1:09:18
than if you have dead tumor where you're not making
1:09:20
by product or waste product in this case poop
1:09:23
then you're not gonna be able to measure
1:09:24
that that quantifiable a level so
1:09:27
yeah that's how I've been sort of
1:09:28
seeing as how CT DNA is and what we're actually
1:09:32
measuring is we're actually measuring indirectly
1:09:35
live tumor cells in the body
1:09:38
yeah that makes sense um kind of on the
1:09:41
I I apologize I'm kind of teasing
1:09:43
teasing some tricky questions for you guys but
1:09:45
have you ever seen in your practice like CT DNA rise
1:09:49
dramatically and then drop immediately after like say
1:09:53
Y90 ablation Hepzato like the PHP treatment
1:09:57
are you are you guys noticing anything
1:09:59
like that ever and and if so like
1:10:02
I mean what does that mean
1:10:05
so the one of the interesting features of CT
1:10:08
DNA is the half life
1:10:10
the half life is 30 to 90 minutes
1:10:13
so you could certainly see a spike I believe
1:10:18
if you drew when a lot of cell death was going on
1:10:22
which is exactly what we wanna see right
1:10:25
but that signal is gonna be gone super quick
1:10:28
right so 30 to 90
1:10:30
minute half life means that in 30 to 90
1:10:32
minutes half of it's gone it's been degraded
1:10:35
uh and then double that time and it's all gone
1:10:37
right so yes I believe you can see the phenomenon
1:10:40
you're describing
1:10:41
but I think that we don't see it just because the half life is so short
1:10:45
so you would you would have to really time the draws
1:10:48
super super specifically
1:10:50
you would have to be like okay like you drew
1:10:53
like you did Y90 now you're doing
1:10:54
a draw and then 30 minutes later do a draw
1:10:56
that would be an interesting correlation to see
1:10:59
I just know I've heard of just a few random
1:11:01
random patients who
1:11:02
they were like oh my goodness I had
1:11:04
I had Y90 done and then my CT DNA spiked to like 500
1:11:08
and then the next time they drew it
1:11:10
it was all the way down to zero again and obviously
1:11:12
you know the time between those draws
1:11:14
was probably a month
1:11:15
so that was all hopefully you know
1:11:17
enough time for that like you said that half life to disappear
1:11:20
but I just I think that's a really
1:11:21
interesting phenomenon that kind of correlates to the
1:11:24
the idea of like cancer poop um I guess like my
1:11:28
mediocre understanding of biology says that cells
1:11:31
that grow discard
1:11:33
right they discard cell waste
1:11:34
and cells that are dying discard cell waste
1:11:37
so you might have cancer
1:11:38
poop that's coming from cells that are just actually
1:11:40
continuing to die or you might have it because it's
1:11:43
really really actively growing and
1:11:45
continuing to discard you know everything
1:11:47
it's not using to grow um
1:11:49
I don't know if that makes any sense
1:11:49
yeah and maybe the poop was the cells that already pooped and died ha ha
1:11:54
together so yeah I agree with
1:11:56
Doctor Krainock and Doctor Ma
1:11:57
I also wanted to add and also to your point
1:12:00
that it depends on what type of treatment
1:12:02
we're talking about there are some treatments
1:12:04
that have a gradual effect for example if radiation
1:12:06
therapy or Y90 we're talking about it doesn't
1:12:08
you know kill the cells right away uh
1:12:11
so maybe gradual thing that said
1:12:13
we have seen this pattern that we actually did um
1:12:17
CT DNA testing uh
1:12:19
not necessarily with Natera but
1:12:20
we were curious to see if this happens with radiation
1:12:22
and how soon it happens
1:12:23
and you know usually a few days after radiation we see
1:12:27
a spike and then um it gradually goes down
1:12:30
better to do the CT DNA as a baseline right before
1:12:34
giving the Y90 yeah that makes sense agree
1:12:38
another example would be you know if you surgically
1:12:40
remove the tumor you know from the body
1:12:42
you know we do that on occasion
1:12:44
from time to time depending on
1:12:45
stage of disease but you know if you have a high level
1:12:48
and once you remove the only
1:12:50
source of where the DNA is coming from
1:12:52
um you can see that level drop
1:12:54
you know quite dramatically
1:12:55
even in some cases it can go down to zero
1:12:57
yeah absolutely
1:12:59
alright well okay last question
1:13:01
for patients who want to know more about CT DNA
1:13:03
specifically about the Signatera test
1:13:05
where should they go for information
1:13:07
and then for a doctor perspective
1:13:09
if you are a patient who doesn't see Doctor
1:13:11
Montazeri or Doctor Ma or a patient uh
1:13:13
a a doctor who currently utilizes
1:13:15
something like Signatera's test
1:13:17
how could you go about bringing this up to your doctor
1:13:19
if you're interested in having this test done so
1:13:21
doctors keep that in you know park
1:13:23
we're gonna answer that in a sec Doctor Krainock um in
1:13:26
in honor of your time I want to let you answer
1:13:27
that question for where they can get more information
1:13:30
yeah so you could visit the website
1:13:32
Natera.com um you can also reach out to me directly
1:13:36
so my email is my first initial and last name
1:13:39
MKrainock@Natera.com
1:13:46
shoot me an email um if you have specific questions
1:13:49
if you just wanna
1:13:51
generally learn about the test visit the website
1:13:53
we have all kinds of patient downloads and brochures
1:13:56
one thing I wanted to mention
1:13:58
I saw something about I think you touched on it Danet
1:14:00
a question about slides
1:14:03
if you're if the if the patient's talking about slides
1:14:06
that a pathology department has we can use slides
1:14:10
so we can scrape the slides
1:14:13
um so I just don't want to confuse people
1:14:15
we can't use sequencing done by another lab
1:14:19
but if it's if you're talking about your tumor
1:14:21
was sectioned and put on slides like every tumor is
1:14:25
and it's sitting in a pathology department
1:14:27
but the blocks been exhausted it's just slides
1:14:29
if that's what you're describing
1:14:30
we can use that just FYI
1:14:33
okay so that's you know worth exploring
1:14:35
unstained slides right just unstained yeah
1:14:38
uh one H&E yeah and and the rest unstained
1:14:42
I think we need at least one H&E
1:14:44
and it kind of just sounds like if you're not sure
1:14:47
right that you could have your doctor
1:14:48
investigate and also connect with Natera yeah
1:14:51
to just make sure that that's a good idea you know
1:14:53
that they can clarify
1:14:54
like okay if there's some level of disease
1:14:56
sample available is this
1:14:58
usable for the test or not and just kind of let them
1:15:01
that's a great point it's not up to the patient to go figure that out if you're
1:15:04
interested our our team will will will
1:15:06
find out for sure that's a really good point Danet
1:15:09
awesome okay um Doctor Montazeri Doctor Ma patients
1:15:13
who don't see you or don't see a doctor
1:15:15
who uses Signatera or a CT DNA test
1:15:17
what would you say to them
1:15:18
bringing this to their doctor
1:15:19
and like kind of how they could approach that
1:15:22
I guess I could start um you know um
1:15:25
so I've been a very heavy user
1:15:26
of circulating tumor DNA in my practice but
1:15:29
you know I would say not every provider
1:15:31
is you know even familiar
1:15:32
with it you know and so having this sort of like
1:15:36
uh webinar here podcast
1:15:37
I think a lot of patients
1:15:38
are starting to learn about what are their options
1:15:40
you know in terms of like cancer monitoring
1:15:43
and so you know for patients who are interested in
1:15:45
doing things like CT DNA monitoring
1:15:47
whether it's for surveillance or treatment monitoring
1:15:50
I'd say start off by at least asking your provider
1:15:52
you know I think nowadays with CT
1:15:55
DNA being so heavily used
1:15:56
you know in a variety of different settings
1:15:59
not just melanoma but for other cancers
1:16:01
I think every provider at this point is at least familiar
1:16:03
with it
1:16:04
and it's an opportunity for them especially if they don't have it available in their practice
1:16:08
to to push themselves to look into it and potentially
1:16:11
bringing it in as an option to their clinical practice
1:16:13
and so um as usual you know um
1:16:16
Doctor Montazeri and myself
1:16:17
we're we're primarily at academic centers
1:16:19
you know where we're always pushing
1:16:20
the limits in terms of research innovation um
1:16:24
but you know it's never wrong to to get great
1:16:26
care as well as in the community
1:16:27
and even though they may or may not have the test
1:16:29
available
1:16:30
it's always reasonable as a patient to always ask
1:16:33
what are my options
1:16:34
can I do something that is available out there especially
1:16:37
for something like Signatera
1:16:39
which is commercially available yeah absolutely
1:16:44
okay
1:16:44
well you guys thank you so much for your participation
1:16:46
as our audience we could not do this without you guys
1:16:49
you guys have been a wonderful audience
1:16:50
if you guys are listening to this recording
1:16:52
on our edited YouTube channel then
1:16:55
please make sure you're dropping those questions
1:16:56
in the description or in the the YouTube chat later
1:16:59
and we will do our best to come back and answer those questions
1:17:02
but for now let's give a huge thanks to Doctor
1:17:04
Krainock Doctor Montazeri and Doctor
1:17:05
Ma for being our guest
1:17:06
speakers here and just having this discussion with us
1:17:09
um and again huge thanks to our sponsors um
1:17:12
Natera Castle Bio Sciences Aura Bio Sciences
1:17:16
Delcath Systems Ideaya
1:17:17
Biosciences and Immunocore for making sure that our
1:17:20
um our webinar can happen
1:17:22
and we look forward to seeing you guys for quarter
1:17:23
three um in the meantime
1:17:25
we've got ASCO to look forward to this summer
1:17:27
that's a lot of the doctors are heading
1:17:29
there I think all three of these doctors
1:17:30
are actually heading to ASCO next week in Chicago
1:17:33
if you're not familiar ASCO is one of the biggest um
1:17:35
cancer
1:17:36
like research conventions where people are presenting
1:17:38
you know abstracts
1:17:39
they're presenting research they're presenting
1:17:41
clinical trial data if we have any that's matured
1:17:44
like all of those kinds of fun things so stay tuned
1:17:46
with A Cure In Sight
1:17:47
we've got Eye On Research happening at the end of July
1:17:49
maybe beginning of August
1:17:51
um so make sure to stay tuned
1:17:52
for that and we will see you guys next time bye guys
1:17:56
Bye everybody thanks Bye thank you