As one of the most commonly diagnosed cancers among women, new developments in the treatment of breast cancer have the potential to save millions. Immunotherapy is one area where that potential is soaring. At the 2020 CRI Virtual Immunotherapy Patient Summit, we hosted a special breakout session on breast cancer and immunotherapy to educate and empower patients, caregivers, and advocates.
Sylvia Adams, M.D., director of clinical breast cancer research, and Victor Ty, BSN, RN, oncology clinical research manager at NYU’s Perlmutter Cancer Center led the breakout session and answered questions from the audience.
Dr. Adams opened the session with a brief overview of immunotherapy for breast cancer. She explained why immune checkpoint inhibitors are often given in combination with chemotherapy, especially for triple negative breast cancer. Chemotherapy, which targets and prevents tumor cells from replicating, can be a powerful but potentially short-lived treatment. Checkpoint inhibitors can train the immune system to recognize and actually kill the tumor cells with the potential for long-term protection. The interplay between the chemotherapy and immunotherapy treatments can, therefore, improve the likelihood that breast cancer retreats to undetectable levels.
Combination therapies for breast cancer are developing rapidly following the first FDA-approved checkpoint inhibitor for triple-negative breast cancer in March 2019. Dr. Adams encouraged breast cancer patients and caregivers to explore breast cancer clinical trials that offer access to promising chemotherapy and immunotherapy combinations. She noted that participation in trials not only provides access to the most cutting-edge research but also drives science and benefits future patients.
Victor Ty emphasized, “It is really, really important to be proactive with your diagnosis. Clinical trials today can be utilized very early on in your cancer journey. Some of the trials are given just from newly diagnosed cancer patients today. Ask your oncologist about clinical trials.”
Moreover, Dr. Adams underlined the importance of communicating with your health care team while receiving immunotherapy. Every side effect, however small, is crucial to share with your team. If a side effect is identified early, the team can manage it by adding steroids or changing timing in the regimen—so effective treatment can continue.
Finally, Dr. Adams and Victor Ty discussed on how exciting the future of immunotherapy for breast cancer is. Dr. Adams reflected, “it's so gratifying to see more patients who are alive four years later without any cancer on their scans.”
BREAST CANCER AND IMMUNOTHERAPY BREAKOUT SESSION TRANSCRIPT
Tamron Hall: Hello, and welcome to day two of the Cancer Research Institute's first ever Virtual Immunotherapy Patient Summit. I'm Tamron Hall, and it's so wonderful to see many of you back with us after yesterday's informative and inspiring program. I know you're ready to take a deeper dive on how immunotherapy is helping patients with cancer. Now, if you're joining us for the first time, now don't worry. Our entire program will be made available for you to watch on demand. So we've got that. Let's get started.
I'd like to kick off day two first by taking a moment to acknowledge our sponsors, whose generous support has made this program possible. We would like to thank the cancer centers that have also helped to make our summit possible. Each of our partners offers valuable support and services. So we encourage you to take the opportunity to get to know them too.
If you'd like to share your experience on social media today, please be sure to use the #CRIsummit. That's #CRIsummit. This is your chance to connect with immunotherapy experts and ask them your questions. So please leave them in our Q&A box throughout today's program. Today we're joined by another exceptional group of doctors with expertise in immunotherapy. Their bios are linked above if you want to learn more about them, we're very grateful to have them with us here. We'll be focused on specific cancers throughout the day in more intimate sessions designed to answer your questions on breast cancer, ovarian cancer, prostate cancer, lung cancer, and melanoma.
You're welcome to sit in on all of the sessions today or come back when it's time for yours to start. We'll be right here.
Let's begin with our Breast Cancer Immunotherapy breakout. We're joined by Dr. Sylvia Adams and Victor Ty from the Perlmutter Cancer Center at NYU Langone Health in New York City. Dr. Adams is the director of the Breast Cancer Center at NYU Langone where she works closely with oncology clinical research manager, Victor Ty, and together deliver the best care possible for breast cancer patients. We also have with us Brian Brewer from the Cancer Research Institute, who will be sharing your questions with the experts. So please be sure to put them in the Q&A box. Dr. Adams, Victor, Brian, let's learn about immunotherapy for breast cancer.
Sylvia Adams: Thank you so much, Tamron, and the CRI team for putting this incredible opportunity and resource together for patients. It's a pleasure to be here. Just to start, I was asked to give a very brief overview of immunotherapy for breast cancer. So since we are going to discuss breast cancer today, I want to start the subtypes of breast cancer because it makes a very large difference which subtype the patient has and how immunotherapy can potentially work for those patients. So you see in this circle that the majority of breast cancers are hormone sensitive. They are estrogen-receptor-positive. That's about 72% of all our breast cancers. And then the remaining subsets are divided to HER2-positive breast cancer approximately 20%, and triple-negative breast cancer approximately 10-15%. And just in general, I want to mention triple-negative breast cancers have that name because they're negative for estrogen, progesterone and HER2 receptors.
And they're the most difficult subtype currently to treat. And that's where most of the efforts so far have actually been an immunotherapy because we've learned that those tumors in particular can be immunogenic. Meaning they can be seen by the immune system, which is actually very, very exciting information because it means that when somebody is diagnosed with breast cancer, at the time we obtain a biopsy and look at that biopsy under the microscope, you can actually see killer cells from the patient sitting inside the tumor ready to act. They have been shielded and we will talk about the mechanism of action very briefly, but that shield prevents these T-cells from killing cancer cells, but we will see how we can actually overcome that.
So this is the overview of breast cancers, briefly majority being hormone positive. Some of them being HER2 driven and a small number, but very aggressive subtype of triple-negative breast cancer.
So for breast cancer, so far the approvals from the FDA, meaning that we have the ability to give these drugs in the clinic to patients even off outside of a clinical trial are only currently in combination with chemotherapy. And this is just to show you, why do we combine chemotherapy with immunotherapy in breast cancer. That's slightly different than what you see for melanoma, for instance, or even for lung cancer. And the rationale is that the triple-negative breast tumors are actually sensitive to kill by chemotherapy. That usually is not very long lasting, but initially it can be very powerful. And as you see on the slide in red, the tumor cell and the cancer gets actually destroyed by chemotherapy sometimes also by radiation or other targeted therapies, such as HER2 therapies.
And with this breakdown of the life cancer into these particles, the patient's immune cells, the dendritic cells, you see those dendrites come out. Those cells are actually picking up these tumor pieces and showing them to T-cells thereby educating our own immune cells to find tumor cells and then kill. So on the next diagram, you will see that the killer cell now that it's actually primed to recognize tumors can actually attack the tumor. So on the next slide, please.
So here you see that the cancer cell is in close proximity to the killer T-cell. And as you can see, also the PD-L1 PD access. These are just two molecules where cells can communicate with each other. The cancer has designed that molecule to shut down, to dampen that killer cell attack. And therefore the tumor cannot be destroyed by the patient's immune system. So there's a couple of animations and you can see those as soon as we come up with the PD-L1 shield here.
So once you block that pathway of PD-1/PD-L1 the killer cell gets energized and can actually attack and kill the tumor cells. So this is the pathway for very successful stimulation of our own immune response, but in breast cancer, as mentioned, it is typically given together in combination with chemotherapy. However, later on when patients are on this combination for several months or even years, one can eliminate the chemotherapy component and just continue with the immunotherapy.
So there are so many studies that have been done in thousands of patients that we're very grateful for participating in clinical trials. And you actually met one of the patients from NYU on this summit before, Karen. She's been just an example of how successful these therapies can be for triple-negative breast cancer that she had. Currently, there is no evidence of cancer and also the value of clinical trials.
So what I wanted to highlight here is that especially for triple-negative breast cancer, there is great promise for the combination with chemotherapy and immunotherapy. And there's actually an approved combination for patients who have that PD-L1 in their cancer when you look under the microscope and you stay in those tumor cells for it. There are certainly many more clinical trials ongoing in all subtypes of breast cancer, including in hormone-positive breast cancers, HER2 overexpress breast cancers. We are learning more and more about how other subtypes react we may have. We may have to have different strategies for those such as maybe bringing in hormonal medicines to dampen the immune counteraction or even targeted therapies such as CDK4/6 inhibitors, which are already in the clinic just to stimulate the immunity more in those subtypes.
But the most important thing is to really consider clinical trials and enrolling in them because that really drives our science and benefit to future patients. So I think this was just a general introduction for you and now we are ready to answer your questions.
Brian Brewer: Well, thanks so much Dr. Adams, Victor, again, welcome. I'm Brian Brewer from the Cancer Research Institute. We do have a number of questions coming in. This is a very exciting topic and an exciting time in breast cancer treatment when it comes to immunotherapy. So why don't we just jump right in? One of the first questions we received is, what are some of the most promising clinical trials right now for breast cancer?
Sylvia Adams: So that's a big question, right? We won't be able to answer that in two minutes, but in general, I encourage everyone to look at clinical trials to look through them and see where they're eligible. Talk to their physician about it. I think the most exciting ones right now are to get to select patient groups who have not yet benefited from immunotherapy and have different modalities studied to potentially have that same benefit. So we know in triple-negative breast cancer, the approval from the FDA is based on immunotherapy, atezolizumab with chemotherapy, nab-paclitaxel. Only that nab-paclitaxel and no other chemotherapy is approved in that combination.
So there are studies that are currently ongoing for patients who are PD-L1 negative. So they are not really eligible or benefit from that combination. So that subset of patients with triple-negative disease who is PD-L1 negative and metastatic disease is currently really the most important group of patients to study. Also we have to learn about once a cancer grows on immunotherapy, similar to what we do in melanoma or other disease types. Do we continue the immune therapy just with a different chemotherapy backbone, or do we add additional immunotherapeutics? And I think the exciting trials that are out there right now look at different molecules. So it's not just the PD-1/PD-L1 axis, it's many other molecules called Tim-3, LAG3, OX40 many, many different ones. And on those are all being tested in these cancers. And I think they hold great promise. So for triple-negative, we talked about that. For hormone-positive breast cancer. We have a trial that used to involve hormone-positive patients, and there was such great need for that.
So I think that is another area where we need to make a lot more progress. There's one study coming up that we are also opening that looks at a multitude of immunotherapy combinations given for hormone-positive metastatic breast cancer after the tumors are no longer responsive to endocrine therapy to hormonal therapy. So that is very exciting and I think it is important to reach out. And I'm going to actually hand it over to my colleague, Victor, who is our wonderful research nurse. Who's helped many patients navigate the way to find trials and then also to accompany them through the entire process of clinical trials.
Victor Ty: Hi, thank you, Dr. Adams. Hello everybody. I'm excited to be here like Dr. Adam said, we at NYU Perlmutter are very active in helping patients navigate through their cancer journey. It is really, really important to be proactive with your diagnosis. Clinical trials today can be utilized very early on in your cancer journey. Some of the trials are given just from newly-diagnosed cancer patients today. So it's important to find those trials. Ask your oncologist about clinical trials.
If you're a little bit more savvy, you can go to a resource guide that CRI has compiled here. It lists a bunch of different websites of different cancer centers around the country and around your area. And those websites actually has the detail of the eligibility criteria, where you can match your diagnosis with and there's research team contacts in those websites where you can reach out to. I'm one of those folks who actually answered these questions directly to patients. We get excited when we see these questions because we see that patients are proactively seeking answers to their cancer. So we encourage you to please reach out. Don't hesitate to ask questions. It'll give you more options for your cancer treatment. Thank you.
Brian Brewer: Well, thanks so much. During yesterday's session, we were briefed on what clinical trials are and some of the specific considerations for immunotherapy clinical trials. So Dr. Adams and Victor, I heard you both say now that for some patients who are newly diagnosed, a trial may be an option, it's not just a last resort, which is a common misconception.
Sylvia Adams: Absolutely. In fact, actually for, especially if you are considering immunotherapy, the most likely benefit is going to be upfront. The earlier you can incorporate that into your treatment regimens the better. I think if your physician is not discussing trials, I think you should definitely also ask for a second opinion. It is very reasonable to do that these days. So yes, it should be relatively early on in your diagnosis, pretty much at the beginning of your journey. I think the exciting part is now there's lots of studies in triple-negative breast that show when you actually adds the immuno therapy. And that's been shown now with pembrolizumab and atezolizumab that if you add that to the standard chemotherapy before surgery, even that the chance that there is no cancer left at time of the resection is it's actually very exciting.
And probably it may get approved soon by the FDA. So that is increasing your chance for cure in the first place. So when the cancer is very early, but the other reason why I actually want to include immunotherapy in the advanced setting as well, is it's the only modality we have that has the potential for long lift responses. Some of us may want to say cures because the benefit of activating your own immune system, it has memory features. It really can contribute to a very long freedom from metastatic breast cancer.
Brian Brewer: Do we have any idea why giving immunotherapy at the beginning of treatment in conjunction with a standard chemotherapy may produce better results ultimately, and even longer lasting or durable responses? Why?
Sylvia Adams: I think in general the tumors become somewhat more mutated and they change over the time when we give chemotherapy, because they're trying to evade the attack of the cytotoxic therapies. So they are becoming harder to be recognized by the immune system. So I think any line down the road is as always a lesser chance of response.
Brian Brewer: So that actually addressed another question that we had received earlier as people registered for today's event around, does one need to discontinue one's treatment in order to begin immunotherapy? But it sounds like combinations are a great and promising way to go?
Sylvia Adams: Yes, but should be part of the original treatment. So you don't have to discontinue the chemotherapy. Yeah and breast cancer so far it's only combinations because the chemotherapy is actually essential.
Brian Brewer: So I'll throw this to both of you. As a head of an individual's care team or essential member of a patient's care team, how do you make a decision with that patient on what treatment approach they should try given that there are all these new strategies? How do you determine who may or may not benefit from an immunotherapy combination?
Sylvia Adams: For me, obviously it's the goal of the treatment that we have to figure out first. So it is always, one of the goals is always survival. For metastatic patients, it means to really extend that survival and have good quality of life with the treatments available. Then we discuss the values for the patients. For earlier breast cancer is to use the most effective combination therapies upfront to make sure that there is no breast cancer occurrence down the road. So it's always with the eye to longevity and curing cancers and increasing the odds for that.
Brian Brewer: Victor, any thoughts on that?
Victor Ty: Yeah, so being proactive early on in your diagnosis and learning about the options of immunotherapy, for example. It adds on to your regimen. You have a list of drugs that you can take. If you're in a metastatic setting, for example, there's been a much set and you want to have the extra option of immunotherapy. So if you add it on early on like Dr. Adam says, then you just added a good portion of your cancer journey obviously and hopefully you have all the other standard of care options in your back pocket when you need them.
Brian Brewer: So we hear that there are different types of breast cancer, depending triple-negative. Some stem from different types of mutations. What are some of the key mutations that a patient can expect to be looked at when undergoing consideration for immunotherapy?
Sylvia Adams: I think the best studied ones are really the ones that are very frequently enriched in triple-negative breast cancer patients. So these are the BRCA genes, the breast cancer and ovarian cancer syndrome genes. And those tumors somehow seem to be a little bit more visible to the immune system. They also seem to be easier to kill with chemotherapy. So that's really a nice combination. And plus we have specific drugs that target directly, these BRCA mutated tumors, such as the PARP inhibitors or olaparib and veliparib. So they can be part of that regimen upfront because the most cell kill we get when we add immunotherapy to it, the better it is really to strengthen the immune response to the tumor. So I think it's the BRACA mutation genes that are the main ones.
Anybody who has triple-negative breast cancer, especially if it's metastatic should be tested for BRCA mutation, because you have way more different treatment options available to you and also it helps the team to decide which chemotherapy to choose if it's a platinum versus taxane. It really has treatment implications and certainly it has many other implications for the family as well.
Brian Brewer: Let's ask another question about immunotherapy and its impact, if any, on fertility. Is there any connection there? That's another important question we received.
Sylvia Adams: So conceptually it should not, but there are certainly no studies that we have because in the last 10 years, I think when the immunotherapy and I'm talking specifically the CTLA-4 anti PD-1 antibodies, when they were tested, they were mostly tested in advanced cancer patients that were not afterwards seeking pregnancy. So we really have limited information on that, but conceptually, it should not really affect the ovarian function, but since we gave it together with chemotherapy in breast cancer, it certainly has an impact on fertility from the chemotherapy perspective.
Brian Brewer: I see. Can you talk a little bit then about another marker called tumor mutational burden or TMB? And what does that mean? What is its potential significance in breast cancer immunotherapy?
Sylvia Adams: In breast cancer it's not that frequently high. And I think a high tumor mutation burden means that the tumor is so abnormal that the immune system has multiple areas to see that it is foreign and kind of be able to mount an immune response to it. So it's used as an indicator of probably likely good chance to respond to immunotherapy in other cancers that is the case. In melanoma and lung cancer, especially because of the smoking, but in breast cancer it's just a small subset of women who have tumors that have a high TMB. So it's not one of the typical selection criteria that we have, but if somebody has that test done, and if you do for instance, the genomic assays on the tumor, and you have a result with a high tumor mutational burden, then certainly you should ask about immunotherapy because it's approved for high mutational burden.
Brian Brewer: Can either of you speak to just the idea of immunotherapy and how it's introduced to a patient when they're newly diagnosed. Who discusses that with them and how do you explain what it is to them generally?
Sylvia Adams: So I'll start and then Victor, will probably talk a lot about the different side effect panel but when we have newly diagnosed patients or anybody with cancer, who has even a progression on a prior regimen, the discussions are very, very detailed, right? It's not like, "Okay, here's your drug and you go." It's an an hour discussion. Sometimes two hours, there is even multiple discussions in a row. Family members are encouraged to come in so that they hear the same information as well, and they can mull over it afterwards. We give also information in printed form to the patients.
So what's different about immunotherapy versus chemotherapy is that side effect is actually quite different. So you don't expect the hair loss, the lowering of the blood counts the nausea and all that with the immunotherapy, but because it is such a strong immune stimulator, it can actually potentially stimulate inflammation throughout your body and could inflame organ such as your thyroid or other glands or your bowels or your skin or your liver. So it has a potential for a whole different spectrum of adverse events or side effects. Patients need to know about that. So in breast cancer, again, if you use the combination, you educate the patient, both about the chemotherapy side effects and also the immunotherapy side effects. It's important to alert everyone to call for problems. So this is where Victor can actually give you some more feedback.
Victor Ty: So, typically Dr. Adams, would introduce us sort of to the patient our team of clinical research nurses, the NPs, we all work in collaboration with one another to do this really extensive education to the patients. If the patient is getting immunotherapy with chemotherapy, immunotherapy side effects, like Dr. Adam says can involve any of the major organ systems. So the big four that we encounter in a lot of our patients are fatigue, skin rashes, typically early on in like first infusion, intractable coughing that doesn't go away. We would like to monitor that. Diarrhea is one of the big ones. We like to establish baseline with patients with diarrhea, what is your normal bowel movements? Please report to any changes that may happen because all of these changes, although minute, we can nip it in the bud prescribing specific medications. If it ever gets worse, patients can be treated with steroid therapy.
So the take-home is really speak to your clinicians, report everything because the sooner that we know about it, we can act on it. Like Dr. Adam says, if you end up in a little bit more severe adverse events and you're in the ED, in an emergency room, make sure to let those doctors know that you're in immunotherapy because that will guide them also on how to address your specific symptoms at that time.
Brian Brewer: So there needs to be a great deal of communication?
Sylvia Adams: Yeah.
Brian Brewer: The trust between the patients, even the caregivers and the healthcare team. So I wonder like, we often hear sometimes, doctors will give their cell phone numbers out to patients and say if you... Especially with immunotherapy or if they're in a clinical trial, is it that level or is it individual or how often, how frequently do you engage with someone who's on treatment?
Sylvia Adams: Yeah, so Victor certainly gives his phone number to all the patients and they reach out if they're very comfortable about that. But yes, access to the team is important 24 hours a day. And they know that and we try to really explain a lot in advance so that they know when they should call and what we can do about it. Because if you find side-effects early, you can easily treat them by adding some steroids to the treatment regimen or even holding the drug for a week or two or even a month that usually is not detrimental to the cancer therapy, but it's important so that those side effects don't become worse.
Brian Brewer: What if someone has not received an immunotherapy yet, has received some other standard form of treatment and has no evidence of disease and has been disease free for let's say a significant enough time, period, might she or he in consider enrolling in a clinical trial to prevent recurrence and if so, what would be available for them?
Sylvia Adams: So the prevention of recurrence clinical trials are really only accessible at the time, really when you are entering that state. Because they are certainly studying if the cancer of occurrence is diminished and to have really a fair scientific study, you have to give that opportunity to everyone upfront. So you can say, "Oh, I'm 10 years out and I want to prevent recurrence. Can I now enter the trial?" Because by definition, you are already in a much better, safer place for recurrence than somebody who has maybe two months out. So, no. So later on you're probably not eligible for a clinical trial, but that's why the earlier you think about those things, the earlier you seek opinions and educate yourself. It is really crucial to do this early on.
Victor Ty: We are definitely accessible to the patients. We have our on-call folks that they can call on off hours and on the weekends but being in a clinical research you have a team of clinicians that you can reach out to at any time. We very openly like Dr. Adams says, educate patients to reach out for anything. That way we can act on very quickly.
Sylvia Adams: I think one of my mentors used to say that any side effect is considered a side effect from immunotherapy, if the patient's on it until it's proven not to be. So you've got to just assume every complaint is a potential inflammation and that serious and needs to be taken care of.
Brian Brewer: Very, very good advice. We hear that all the time. It's also important. So can't stress that enough, again, in the communication. So in the news these days of COVID, we hear an awful lot about vaccines and development for COVID, but what about vaccines for breast cancer? Where are we there or where are we soon to be?
Sylvia Adams: So I think that the different studies over a couple of decades now for breast cancer and I think so far have shown that you can kind of stimulate the T-cell to recognize the tumor, but it's not the strongest signal yet. So I think they have to really be combined with the checkpoint inhibitors, such as the PD-1/PD-L1 drugs. And then the newer generations actually are looking at a tumor that's specific from the patient at these mutational or neoantigen, these newer things that each tumor develops when it's growing and mutating. There is some promise to that, but I think we're not as close to using that as all the other immunotherapy.
So definitely we have to keep our eyes open and follow that research, but the approvals and the use of the checkpoint inhibitors is much more powerful and advance. So unless you combine that with the vaccine, I think the vaccine alone is probably not useful.
Brian Brewer: Okay, we're almost out of time, we have three minutes, but please continue to leave questions in the Q&A, if we don't get to everything today, which we likely won't, we can certainly follow up after this events with you at the Cancer Research Institute blog. So please continue leaving those questions. If someone is receiving an immunotherapy and they suddenly, or eventually stop responding or don't respond, are they ineligible to receive another type of immunotherapy? You mentioned that there were many different types of immunotherapy currently under study?
Sylvia Adams: Yeah, so I think that's a great question. Again, look for the trial that are available and there's often combination immunotherapy trials that allow a patient to have had prior immunotherapy. I think it's also the clinical judgment of your physician describing to you what the likelihood is off response to that combination. So for instance, if a patient has done really well for three years on the first line therapy, then you're way more likely to entertain another immunotherapy approach compared to patients who had rapid cancer progression, like a month or two or three into the initial immunotherapy.
So we call that the kind of the lengths of the duration of response. That really goes into the decision making as well as what are the side effects expected? How good in shape they are et cetera, but it's definitely an option. And we've done this with many women that they went on to other immunotherapy trials. And even maybe slightly different chemotherapy backbones. So it's definitely an area that has opportunities for study and that you should look for.
Brian Brewer: So for breast cancers that have spread to other parts of the body or metastasized are patients whose disease has advanced to that stage more or less likely to respond, or really is it really down to the individual patient?
Sylvia Adams: That's a tough question. I think let's just take metastatic triple-negative breast cancer. So I think if you give it alone, the immunotherapy alone, I think the response rates are in the single digit to 25% range. If you give it with chemotherapy, then your response rates can go up to 60-70%. But really what we want to achieve is really a complete response so that you don't see any more cancer on skins and then that, that is maintained. And that currently that you've maintained that complete response for years, that number is relatively small in breast cancer. It's probably in a single digit range, but we do have these patients and we're very excited with them that, that really this seems to be such a useful and powerful modality that we're never stopping to study more and trying to tweak things a bit so that we can hopefully offer this to more patients.
But it's definitely there. And we've seen long-term survivors.
Brian Brewer: Well, I like to hear that. I like to see the smiles on your faces, because that means that there are a lot of-
Sylvia Adams: Very young women with children. And it's so gratifying to see that they are alive well four years later without any cancer on their scans.
Brian Brewer: That's fantastic. Well, I want to thank both of you for being here today again. Those of you watching, please continue to leave questions in the Q&A box and we'll follow up after today's event. Victor, Dr. Adams, thanks so much.
Victor Ty: Thank you.
Sylvia Adams: Our pleasure.
Tamron Hall: Dr. Adams and Victor. Thank you for an informative overview and discussion. While I wish we had more time with you, I look forward to continuing the conversation through CRS blog in the weeks to come. And now we will take a short break before starting the ovarian cancer immunotherapy breakout session with Dr. Kunle Odunsi.
I encourage you to continue to explore the CRI resource guide, which includes valuable resources from our partners and provides instructions on how you can schedule your free and confidential clinical trial navigator consultation. If you're interested, thank you again. And we'll be right back.