Published on February 26, 2020
- Minimal or measurable residual disease is a test used to search for one leukemic cell per 10,000 cells in a patient sample.
- Initial treatments for ALL are relatively uniform. Patients under 40 can tolerate more intensive treatment regimens.
- ALL care is a team effort. Patients need awareness and education about their condition to communicate their goals to their care team.
Receiving an acute lymphoblastic leukemia diagnosis is scary. Fortunately, Dr. Aaron Logan, from the University of California San Francisco Medical Center, is at the forefront of finding effective ways to treat patients with ALL. Here, Dr. Logan discusses the recommended testing after an ALL diagnosis, understanding genetic subtypes and treatment options available. Watch to learn how more sophisticated testing, more personalized care, and a range of treatment options can give ALL patients and their team hope after diagnosis.
This program is sponsored by Amgen and Adaptive Biotechnologies. These organizations have no editorial control and Patient Power is solely responsible for the content. It is produced by Patient Power.
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Transcript | Patient-Specific Approach to Diagnosing and Treating ALL
Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.
Hello, it's Andrew Schorr with Patient Power, down in San Diego area, and joining us is a noted expert in acute leukemia. It's Dr. Aaron Logan, who's at UCSF in San Francisco. Dr. Logan, welcome to our program.
Good morning. It's great to be with you. Thank you.
So, Dr. Logan, the diagnosis of acute lymphoblastic leukemia is a pretty terrifying diagnosis, and I know you do research in the field, and you treat patients. So, first of all, it comes on pretty suddenly for people, hence the word acute. It turns their life upside down, right?
Indeed. I think any cancer diagnosis is particularly frightening, but if somebody is watching this because they recently learned that themselves, or a family member, has acute lymphoblastic leukemia, I think I would first want to reassure them that this is a curable cancer, and our goal is always to cure people. But I do think one of the most difficult things about blood cancers—because, in general, they tend to emerge rapidly, and turn peoples' lives upside down. It's just the sudden changes that are needed, and where you're at in life.
If you're working, you're going to have to be out of work for a while. If you're taking care of a family member, you're going to have to get some help with that. It really does just turn things upside down and disrupt plans for a while. But the good news is we can control these diseases, and get people back on track for their lives, and continue their work; continue taking care of family members and raising their families. So, I encourage optimism with this diagnosis.
Okay. Now, you've done a lot of science in recent years. It's changed tremendously. Help us understand the change, particularly in understanding what is a patient-specific situation.
So, we've learned a lot about acute lymphoblastic leukemia in terms of different genetic causes of the disease. So, for a long time, we would group ALL—as we call it, acute lymphoblastic leukemia—into two groups: The Ph-positive, meaning that they carried the Philadelphia chromosome, which is a translocation between chromosomes 9 and 22, and it makes a new protein that doesn't normally exist, called BCR-ABL. And, then, the other group was Ph-negative, meaning that they didn't have this translocation.
And, we would split patients into these two groups. About 20 percent of adults are Ph-positive when they're diagnosed with ALL, and about 80 percent are Ph-negative. And, we now have some drugs that we can use to specifically treat the Ph-positive patients. In other words, a drug that targets this new protein that's made, called BCR-ABL. And, those drugs called tyrosine kinase inhibitors—or, TKIs, for short s—have really revolutionized the therapy for Ph-positive ALL. And, so, now the field has been working on better segregating that other 80 percent, because it turns out that there's still a lot of heterogeneity in that other 80 percent.
And, we now know that there are some other genetic mutations—other gene translocations, or other gene point mutations—that can lead to a leukemia behaving like a Ph-positive ALL, even though it doesn't carry that specific mutation. And, so, now what we do is identify what we call Ph-like ALL, and this accounts for another 20 to 25 percent of adults with ALL, and we know that those who have Ph-like genetic mutations carry some higher risk for relapse after they get into a remission. And, this helps guide our therapy for patients to get them into transplant, if it's appropriate, or intensify their therapy, if needed, if they carry some of these lesions.
And, so, now, at the time of diagnosis, it's very important to get an abundance of genetic testing to help the provider then guide the patient down the right path to maximize likelihood of cure.
Okay. So, probably seeing a specialist in ALL, because it's getting complicated, is: What version of ALL do I, or my loved one, have, and what treatments line up with that?
Absolutely. The ALL is a very rare disease. In the United States, there's only about 6,000 people diagnosed every year. And, about half of them are children under the age of 18, so it really means that only about 3,000 adults every year are diagnosed with ALL. And, so, there will be some providers—hematologists, oncologists—who don't see a lot of ALL. And, I do recommend that whenever possible, a patient get a referral to a specialist in an academic center, to at least help guide the right testing; guide the right decision-making about prognosis, and potentially guide therapeutic decisions.
Not necessarily meaning that the patient has to uproot themselves and go to the academic center to get treated. Sometimes, that is appropriate. But, sometimes, people can be treated at home, remotely, you know, 200, 300, 400 miles away from the academic center, but still get guidance from the specialist who sees a lot of ALL, and can guide the testing, and all of these other decisions.
Okay, Dr. Logan, so based on genetic testing, or whether it was Philadelphia chromosome-positive, Philadelphia chromosome-like, or not, then you're going to recommend a treatment plan. So, it's going to vary by person.
So, the initial treatment usually will start before we know whether a patient has a specific gene mutation. With the exception of the Philadelphia chromosome, which there are tests that within two or three days can give us an answer. But the initial treatment actually is fairly uniform, and more based on age than the specific genetic subtype. But, once the patient gets their first cycle, that specific genetic information becomes very important for then guiding what should subsequently happen.
So, it's okay for a patient to get treated at their local community center, but we want to make sure that those providers are reaching out to the academicians who can say, “Well, please get these tests so that once the patient has gone through the cycle, we can help guide their therapy thereafter.”
Okay. You mentioned about age, so how will it vary for kids versus somebody, maybe, 18 or older?
Sure. So, there are pretty significant differences in how children and adults have been treated with ALL. Primarily, because children—especially young children—are very resilient, and can tolerate a lot of toxic chemotherapy; a lot of steroid exposure. Steroids are something that we use a lot to treat ALL. And, unfortunately, these drugs have toxicities that are not well-tolerated by adults of more advanced age. And, so, what the field has done is try to discriminate: What is the age cut-off for using these really intensive regiments that children can tolerate, and where should we start thinking about lower intensive therapies?
And, so, we have identified what we call AYAs—or, adolescents, and young adults. And, there have now been studies in adolescents and young adults up to the age of 40, with pediatric-like chemotherapy demonstrating that that intensive chemotherapy can be tolerated in adults up to age 40, and this is now the recommendation to use an AYA, or a pediatric-like regimen in adults up to age 40.
Now, beyond age 40, there's a lot of heterogeneity across the country in terms of regimens that are used, but in general, they are less intensive than the pediatric regimens. We can still get a very sizable proportion of adults over age 40 into remission, but those remissions tend to not last as long as children, or AYAs, treated with the very intensive pediatric-like regimens.
So, it does have some impact on downstream decision-making if we use a less intense non-pediatric inspired regimen, say for a 45-year-old, or somebody of more advanced age. So, that's where these age discriminations become very important for getting the right therapy up-front to get people onto the right path to maximize likelihood of cure, but then also making decisions downstream if we had to use something less intensive so that we can follow up, and determine what to do after that.
Why not just—a follow-up question about age is, is it chronological age, or is it when you do a physical on somebody, it could be they could be 60, and a marathoner, and in great shape, right?
Absolutely. There's definitely something to biological—or the age phenotype, as we call it. And, certainly, there are patients who are over age 40, that we deem to potentially be fit to receive a pediatric-inspired regimen, and we do that with some frequency. So, it's not necessarily a strict cut-off. The clinical trials that have been done, of course, did have a strict age cut-off.
And, so, some providers may not feel comfortable using the most recent, very intensive pediatric regiment in a 50-year-old, but they may use something that's somewhat similar, and still more intensive than they would give a 50-year-old who is not out running marathons, and has some co-morbidities, maybe from a long smoking history, or some other things that compromise their ability to bounce back from the therapy.
Dr. Logan, in the last few years, we started to hear about the acronym MRD, whether you call it minimal residual disease, or measurable residual disease. And, I know this really plays a role in assessing how it's going in the treatment of ALL. So, maybe you can describe what MRD is, and how is it used; how should it be used?
Absolutely. This has been one of my main areas of research thus far in my career. We actually learned a lot about MRD from pediatric trials. MRD historically has been called, as you already indicated, minimal residual disease, but a lot us feel that we should call it measurable residual disease. Because, what it means is after a patient gets therapy, and they come down from having a lot of leukemia in their body, to having a little tiny bit, that little bit of disease is still measurable. And, if it's measurable above a certain threshold, it can be predictive for the likelihood of having a subsequent relapse.
And, so, for a long time, the Children’s' Oncology Group—which is a network across the country—did studies in children with ALL, and they used MRD testing at specific time points to demonstrate that, indeed, if you do MRD testing at the end of induction, at the end of consolidation and at other time points, you can predict the likelihood that that patient will remain in remission. And, so, this is now trying to be translated into the general world, including treatment of adults across a large number of centers, and that means that the market had to create tests that were available for any provider to order.
Because, a clinical trial, of course, determined which lab would the bone marrow aspirate be sent to; who was going to do the testing; who was going to interpret the testing. And, now, we need a network that allows a provider anywhere in the country to send MRD testing, and get a reliable result back, and be able to interpret that result, and talk to the patient about it. And, so, we now have two methods, basically, that are available for MRD testing to measure this tiny bit of disease that's left after therapy. One is called flow cytometry. And, this is actually a test that's very common across the country, because flow cytometry is actually part of the initial diagnostic workup for a patient with ALL.
And, what flow cytometry is, is where we use antibodies that have been bound to very small florescent molecules, and those antibodies bind to the surface of the cell to different proteins that are expressed, and the combination of antibodies that bind in the florescent molecules that are attached to them can then be put through a machine, and tell us on a cell by cell basis what type of cell that is. And, so, we can diagnose a B-lymphoid acute lymphoblastic leukemia and differentiate it from a T-lymphoid acute lymphoblastic leukemia, and do some other things. We call that immunophenotyping.
So, standard flow cytometry for immunophenotyping is essentially done on every ALL patient to help determine what kind of ALL do they have. But, it's not always going to have deep enough sensitivity to look for MRD. In order to have adequate sensitivity to assess for MRD, we need a test to go down to at least 1 in 10,000 cells, meaning, it should be able to detect one leukemic cell out of 10,000 white blood cells. And, so, there are not that many labs across the country that are able to do flow cytometry-based MRD testing. They're becoming more and more, but they're still limited in their availability.
So, an alternative to flow cytometry that has been developed is a genetic test for MRD, and this is called clonotyping, and the test that's available is called clonoSEQ. What this does is it relies on the fact that a B cell, or a T cell, from which an acute lymphoblastic leukemia arises, will naturally undergo rearrangement of a certain gene, or set of genes, that express proteins from the cell, or on the surface of the cell. These are called immunoreceptors because B cells and T cells are immune cells. And, they express immunoreceptors as part of their normal function and lifestyle.
And, it turns out that we have evolved this very intricate system to make a different protein in every B cell, or every T cell, as the immunoreceptor. So, we have this very, amazingly diverse immune system. So, that's how we can prevent infections from all kinds of viruses, and fungus and whatnot. So, we can actually take advantage of the fact that a patient who has B-cell ALL will have one or more immunoreceptors that have a very specific sequence, and if we can determine that sequence, we can then use that after therapy as an MRD test, which is pretty cool. And, we do that with something called next-generation sequencing.
And, it turns out that with next-generation sequencing, we can actually detect the leukemia down, not just to 1 out of 10,000 cells, but one out of a million. So, this gives us a very deep assessment of how well a patient has responded to therapy and allows us to then make decisions. So, once we get the MRD data, what the provider will do is look at the available data. And, the available data suggests that anyone who has greater than one leukemic cell out of 10,000 white blood cells—another way of expressing that is .01 percent, or 10-4. If there's more leukemic cells than that, then there are many studies now that demonstrate there's a very high risk of relapse in that setting.
And, that information—that MRD test—at the end of induction, or if it isn't done at the end of induction, certainly after the first couple of cycles of chemotherapy—is probably the most important prognostic indicator to help us decide; is this a patient that I'm not so worried is going to relapse, and I'm going to keep them on this regimen, and they're probably going to be cured with the chemotherapy? Or, is this somebody that I'm worried is at high risk for relapse, and maybe is going to need to have alternative therapy, such as immunotherapy—which we can talk about—or, potentially need to go to a transplant as a way to cure their leukemia?
And, so, MRD testing, I think, is now critically important and essential for the management of every ALL patient.
So, now that this super sensitive testing is becoming available, what should the patient, or the family advocate, say so that this is brought to bear so that the doctor and the patient know what's going on?
Right. I think it is very important for patients to be aware of MRD testing, and the importance of it. And, as I mentioned before, it is just the reality that some oncologists are not going to see a lot of ALL patients because of the rarity of the disease. And, ALL is unique in the fact that we have MRD testing available. There are a lot of cancers where this just isn't part of standard practice. And, so, patients—I would advocate that they advocate for themselves, and talk to their provider, and say, “Are you doing MRD testing on me? When are you going to do it? Can you explain the results to me? If you don't know how to get it, can you call an expert, and just find out how to get the testing done? And, they can give you some guidance about how to interpret that information?”
And, I'm always happy—and, I know a lot of my colleagues at other academic centers are always very happy to talk to oncologists who don't take care of a lot of ALL patients, so that we can recommend the right testing be done. We can tell them how to get the test, where to send it, how to interpret it. So, patient awareness can actually be very helpful. And, I look at patient care as a partnership between myself, the provider, the team that I work with—nurse practitioners, nurses and social workers, and other healthcare providers—but, also the patient coming to me and saying, “Hey, you know, maybe you're not aware of this new test, or maybe you're not aware of this new research. Can we talk about it? Can you look into this?”
And, I think, you know, most oncologists should be very comfortable with that. Particularly if it's a disease that they're not seeing a lot of. So, I want patients to never be bashful to ask questions, or to bring in a research paper, or bring in a website URL, and say, “Hey, is this something that's relevant to me? And, how can we make my treatment work better?” And, that's always okay. Definitely, I advocate that patients do that.
This testing that you're talking about, should it be done more than once in the journey somebody has with ALL?
It's a great question, and indeed it should be done more than once, because not every patient who achieves MRD negativity—meaning, that their leukemic cells are not detectible above 1 in 10,000—will actually have the relapse-free survival of that entire group. There are still some patients that can relapse from that setting. It's just a lower incidence. And, so, generally, we will recommend repeated MRD testing as a patient goes through therapy. Certainly, if they are MRD-positive, and they're not becoming MRD-negative after the very next chemotherapy cycle, then that's somebody that we're really worried about.
And, there are now ways of treating those patients differently. There is, in fact, a drug that's specifically approved to treat MRD-positive B-cell ALL. And, we can talk about that. But, for patients who are negative, repeated testing should be done at least every couple of cycles so that if they start to become positive again, then the provider can say, “Okay. We need to watch this,” or, “We need to change therapy,” or, “If we didn't already think about transplant, now we have to think about transplant.” Because, it's much better to treat a patient, and get them on the right path before they have an overt relapse when they get very sick. And, we now have ways of doing that.
Okay. So, let's talk about advancements, then. So, if someone doesn't either stay MRD-negative, or they're not MRD-negative, what are the options?
Right. So, about 30 to 40 percent of patients will not achieve MRD negativity after their first, second, or third cycle of chemotherapy, with most conventional regimens. And, so, these are patients who ultimately are going to have a higher risk of relapse. For a long time, we didn't know what to do at this setting. We knew there was a risk, and we didn't have a specific therapy to apply to that risk. But, for the last couple of years, there's been one drug that's been FDA-approved specifically to treat the scenario of MRD-positive B-cell ALL. That drug is called blinatumomab. The other name is Blincyto.
And, what blinatumomab is, is it's an antibody that binds to the surface of the leukemia cells, and the other side of the antibody actually binds to an immune cell called a T cell. So, it brings the T cells, and the leukemic cells together, so the T cell can kill the leukemic cell. And, this is very effective in the MRD-positive setting. When blinatumomab is used for MRD-positive ALL, 80 percent of patients will actually become MRD-negative after just one cycle of therapy. One cycle of therapy is 28 days of continuous infusion of this antibody. And, so this is very, very useful to get people into an MRD-negative remission.
And, when we use this therapy, the plan is then to take them to an allogeneic stem cell transplant after they're MRD-negative, following the blinatumomab, because we know that the likelihood of the transplant curing the patient is higher if they go into the transplant MRD-negative. And, so, the only disease in the world for which there is an approved agent to treat MRD positivity is B-cell ALL, and it really has revolutionized the way we think about the importance of MRD testing; how we act on those results, and how we can guide patients down the right path, with that agent, to a transplant.
Okay. And, you used the word earlier immunotherapy. So, does Blincyto fit into that, or are there other drugs being developed in trials as well?
Absolutely. Immunotherapy is a broad category of therapies across the oncology field, and it can encompass various things. Blinatumomab—this antibody that binds to two different proteins to bring cells together—is what we call a Bi-Specific T cell Engager. And, there are now a class of drugs being developed that have this similar activity of bi-specific engagement across two cell types to bring them together. And, they're being employed now in different cancers. So, bi-specific antibodies, or bi-specific T-cell engagers is one subtype of immunotherapy.
There are some other drugs that are available, specifically for acute lymphoblastic leukemia. One is an antibody called inotuzumab (Besponsa). And, what inotuzumab is, is something that binds to a protein on the surface of the leukemic cells, called CD22, and it delivers a chemotherapy drug to the leukemic cells. And, so this is kind of a fancy targeted delivery of chemotherapy. And, some people would say it's not really immunotherapy, even though it's using an antibody to deliver the cells because it's not relying on the immune system to attack the leukemic cells. It's just using an antibody to deliver the chemotherapy.
But we call these antibody drug conjugates, and this is something that's sometimes talked about in the setting of immunotherapy. Other types of immunotherapy that really haven't gotten into the leukemic world so far are what we call checkpoint inhibitors, that kind of take the foot off of the gas—off the break—on the immune cells that can attack cancer cells. And, we don't really use checkpoint inhibitors in ALL, but there are ongoing studies to determine if they can be combined with other agents. And, that's definitely a type of immunotherapy.
And, then, a final type of immunotherapy is what we call cell therapy. And, within cell therapies, there can be different types. The most common that will be known is what we call CAR T-cell therapy. CAR, C-A-R, means chimeric antigen receptor. And, these are immune cells that have been genetically modified to express a receptor that causes them to specifically recognize and attack the leukemic cells and kill them. And, so, CAR T-cell therapy actually was pioneered in acute lymphoblastic leukemia, and there's an FDA approved CAR-T cell already for ALL inpatients up to the age of 25, because that's the way that the study was done. It's not yet available in patients of higher age.
So, CAR T-cell therapies are a type of immunotherapy that are becoming very, very important for the management, particularly, of relapse acute lymphoblastic leukemia, and there will be further evolutions of these types of immunotherapies to help give patients other options, and better effects, and long-term effects, for relapse of the disease.
I just want to get back to one thing about minimal or measurable residual disease testing. So, if someone had ALL years ago, and they're doing pretty well, is there any reason to do that testing at a checkup down the road?
That's a really fantastic question. So, if a patient is, say, four or five years out from their therapy; they're doing great; their blood counts are normal, I would not advocate for doing MRD testing that far out. If they've done well, they're very likely going to remain in remission. We don't yet know from any specific studies when is long enough from therapy; when is long enough in remission to say that we don't have to do MRD testing. But we do know that most people who have ALL, and who will relapse, will relapse within the first three years.
And, that's why a lot of the treatment programs actually last for three years. There's a lot of intensive chemotherapy up front, but then we go on to what we call maintenance therapies, which are oral drugs for two to, sometimes, three years—to keep people in remission for that duration of time. But, generally, I would say if somebody is three years, or more, out; they're doing great; blood counts are normal—I would not get an MRD test at just a checkup at that point in time. It's a really, really great question. And, I think, right now, the data wouldn't support doing that.
Dr. Logan, you said at the outset that there's a great deal of hope in that in so many cases, you can cure ALL.
You've rattled off more sophisticated testing than ever before, more personalized care, a whole range of treatments, and ongoing research. How do you feel, as a researcher and a practitioner today, when a new patient and family comes to you, on what you can tell them about having, in this cancer, a more positive journey?
Absolutely. So, I think, you know, again, based on the age, I can convey information about the likelihood of being cured with just chemotherapy. With young patients up to the age of 40, with chemotherapy approaches, long-term disease-free survival is upwards of 70 percent. And, so, those patients—you know, most of them are cured because if they haven't relapsed within that three years, they're very likely to remain in remission.
For older patients, we have to say that the likelihood of cure with just chemotherapy is lower, but if they show that they're MRD-positive, and we give them blinatumomab, and take them to a transplant, we can actually cure about 60 to 70 percent of people who go on to a transplant for ALL. So, ultimately, we're actually able to cure the majority of patients who have ALL, as long as they get treated appropriately upfront, and get on to the right pathway based on assessment of their genetics, and assessment of their MRD status as they're going through that initial therapy. The outcomes can be very, very good.
I'm optimistic for every new ALL patient I meet. I tell them, “My goal is to cure you, and get you back to the life that you were leading before this came about.”
All right. Lastly, then, what is the role of the patient and the family in this changing landscape so that they can make sure that they, or their loved one, get state of the art care? Maybe consider being in a clinical trial, as you do more research. What questions should they be asking?
Well, I do think that it's always important to ask whether there's a clinical trial available locally, or potentially if a family has means to move for a period of time to a larger center that's doing clinical trials, because we still have room for improvement. We would ultimately love to be able to cure every ALL patient without ever having to do a transplant, cure them the first time with one regimen.
Hopefully, at some point, we'll get to the point where we can abbreviate the length of therapy, and determine that a patient is cured—not at five years; not at three years, but maybe at two years; maybe at one year, if we get really effective therapy, and we can show that they're MRD-negative at the level of one in a million cells, and that that's predictive. So, we definitely advocate that people get into clinical trial to help get the best type of care, the best type of testing, the most expertise therapy, and guidance of that therapy. And, so, asking about clinical trials is always 100 percent appropriate for this disease, and I would say, really, for any cancer. But, particularly for rare cancers like ALL.
But, beyond asking about clinical trials, I do really, really recommend that patients and their family members ask about the testing, in particular, the MRD testing. Because, one of the things that has taken longer than many of us would like is the implementation of standardized MRD testing by providers who, just by the type of practice that they run, they see one or two ALL patients per year. And, so, they're not always thinking about it. They're not always thinking about the cutting-edge test.
But, if the patient goes in, or their family member says, “Hey, we've learned about—from Patient Power, or other websites—the importance of MRD testing. Do you know about this? Are you testing for it? How are you testing? And, if you don't know about it, can you find out about it? Can you talk to an expert?” Those questions are always, always okay. And, again, I recommend never be bashful about advocating for your own care, or the care of your loved ones. These tests are really important. They're not necessarily on the radar of every single oncologist across the country, and that's just the reality. So, ask about it.
And, I think that, for patients who do ultimately have high-risk disease, or who relapse, it's probably important, in that time, if they haven't already gone to an academic center to see a specialist who sees a lot of ALL—to really consider, even if it's somewhat of a hardship—to really consider going to see an expert—again, not necessarily to have all of the care transferred to a center, maybe a few hundred miles away from home, but at least to get guidance on what is the appropriate way to manage relapsed disease.
Every relapsed ALL patient should be considered for allogeneic transplant—that means a transplant from somebody else. That can only happen at certain centers, and so there's a necessary commitment that needs to occur. And, I would say that even though it's hard—I realize it's hard for people to uproot themselves from their home, or from their work commitments, or family commitments—these therapies are curative, and they're only available at certain centers, so I would advocate, even if it's hard, really find a way to make it work.
And, there are patient advocacy groups, and philanthropic organizations that have monies available to help people travel for clinical trials. There's actually a really great organization specifically to help patients travel for clinical trials. The Leukemia & Lymphoma Society sometimes has resources just to be able to travel and stay overnight to see a specialist. You know, ask your doctor to help you gain access to these things so that you can get the best guidance, the best care, and ultimately have the best outcome.
Well, we're very committed to patients knowing about trials. I've been in two for my blood cancers, so I'm very aware of that. And, thank goodness there is more and more support. And, the FDA has loosened guidelines now to allow sponsors of trials—pharmaceutical companies—to provide more logistical support, as well. Dr. Aaron Logan, I want to thank you for your devotion to people with hematologic malignancies, and all this work you're doing in ALL, and really helping us, and the clinical community, also, understand the changes, and how patients can really get the best, most personalized care. Thanks for being with us today.
Oh, it's been an absolute pleasure. I really value the work that you're doing to spread information to help patients gain awareness about a really complicated disease. So, thank you for what you do. You know, this is teamwork. I always say cancer care is a team sport. It's a privilege for me to be able to help somebody who has a diagnosis that's trying to really disrupt, or even take their life away. And, the things I do, and the things I want to do to help patients can't happen without awareness, and organizations available to help support patients gaining access to these therapies. So, this is teamwork. I really appreciate what you're doing. Please keep doing it. It's super important. Thank you.
Thank you for being on the team with us, and us being on the team with you, and with patients and families. In Southern California—and Dr. Logan in Northern California—I'm Andrew Schorr. Remember, knowledge can be the best medicine of all.
Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.
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