 So today's symposium is called metastasis in immunity how immune cells can help cancer spread or stop it in its tracks And before we get to the program I just wanted to mention that this is a public lecture has been going on for 15 years now And it's a partnership with Cold Spring Harbor and st. John the nursing center with support from Northwell Health And I want to thank to the the team at the Cold Spring Harbor public affairs that puts this symposium together Particularly Jessica Giordano who is here. Thank you Jess. And also the st. John is particularly Kathy Wardell who's somewhere Thank you Kathy And also to our great AV team that helps put this on this great auditorium and our Coastman facilities crew that helped make these events go so smoothly So tonight we have two fantastic women scientists as speakers The first will be Micola Eggeblad. So she's an associate professor at Cold Spring Harbor since 2009 And her research which you'll hear about today has been recognized by several awards including the Pershing Square SOME Prize and the Arab Hope Scholar Award from the Department of Defense and Joining her will be Sylvia Adams Who's an associate professor at NYU and she's the director of clinical research and breast cancer disease management group She's a medical oncologist specializing in caring for patients with breast cancer and she also Conducts research including clinical trials involving treatment of breast cancer Micola and Sylvia are actually collaborators They work together on a project Which is very exciting and we'll hear a little bit more about that tonight And so the format tonight will be Micola will start with around a 20 minute talk or so And there you'll have opportunity to ask her some questions right after her talk And then we'll move to Sylvia as she'll give another her talk And you'll have opportunity to ask Sylvia questions And then we're going to end with bringing both of them up here into these nice chairs And they will answer your questions and after that there'll be a reception So that's the format for the program and we'll start now with Micola so I'm going to talk about Immune cells that help cancer spread and a particularly one type of immune cells called neutrophils And what you're seeing here on this very first slide is Actually strings of DNA in blue DNA doesn't normally look like that in a cell and I'll tell you what it's doing Why it's making these strings and how that's helping the cancer spread so the first thing to know about tumors is really that tumors are much more than just the cancer cells and you can see this on a biopsy of a breast tumor so one of the first thing that happens when you Suspect them you have cancer as a biopsy is being taken and a pathologist are looking at that in the microscope and what they see is Here in blue cancer cells But if you stand forward you'll also notice that there are all these immune cells which here have been stained in brown So you can recognize them so you can see that maybe half of the tumor is not even tumor cells and What we are doing in in my laboratory is trying to understand what are these immune cells doing to the cancer cells Now in this picture, it's all static. It's a dead tissue. It's been taken out. It's been formally in fix It's been cut to slices so we can't really understand how these cells are talking to each other from looking in a microscope this way So to try to understand how are they talking in real time? How are they doing it in live action? We took advantage of some basic discovery research So it had been discovered that jellyfish has a fluorescent protein it's called green fluorescent protein and that fluorescent protein by Martin Shelfie was taken into living organisms and he was then able to make a mouse like this turn in green and then Roger Sheen was able to modify this version of the green fluorescent protein from the jellyfish So we could have not just green mice, but also red or blue mice And now what we are doing is we are taking all these colors and putting them in different cells Some in the cancer cells some in different immune cells and now we can look at it We can see how they're talking So we built a special microscope and then we have now on the microscope a living mouse That's here anesthetized it's breathing the anesthesia gas Which is the same kind of gas that you would get if you were under surgery and then in the Monitor from the microscope. You can now watch the tumor and this is what it looks like You can see the immune cells here in a blood vessel and they are Crawling around and some of them are coming out of the blood vessel and getting into the tumor And we can now start to understand. What are these cells doing to the cancer cells? So the first thing we were interested in trying to to learn was what happens when you give a Mouse or a patient chemo therapy This is one of the most classical types of treatment that are given to patients So what actually happens if we look in the microscope while we're giving the treatment and to do this We were watching the mice for a very long time This is a movie that's been going on for 29 hours after we gave the chemo And you can start to see here in red that a lot of the cancer cells have been killed So we did a trick that they switch color from blue to red when they are dying but I Remember taking that movie there was one of the last movies that I took before I got my own lap And I had been in the room for 29 hours as you can imagine I was dozing off to be honest and then I saw this happening And you can see in green these immune cells type of immune cells called inflammatory cells coming into the tumor So it's almost like an and small they're coming in in very high numbers And this was 4 a.m. In the morning, and I remember thinking this is very strange. I wonder what it means So these kind of Inflammatory immune cells that we were looking in are the type of immune cells that are helping us killing bacteria So here is a movie where we instead of using cancer cells have used red bacteria And what you can see on this movie is how the immune cells inflammatory cells are coming through the blood vessel And they are finding that something's wrong here And they're aligning the wall of the blood vessel and they're coming out and they're finding the bacteria They know where to go and once they find them as you can see here in higher magnification the individual bacteria This type of inflammatory cell doesn't do anything But now another one comes in this is a neutrophil and it starts engulfing and eating these bacteria So these are really very important immune cells for us in terms of combating and in fiction But inflammatory cells also do other things than just killing bacteria They are very critical for what's known as wound healing in the wound healing process The first thing that happens is again that the inflammatory cells come in and they kill the bacteria But then they start the process of repairing the wound They secrete signals that make the neighboring cells start to proliferate to divide So there are more cells to replace the ones that were dead and these make signals to make the blood vessel regenerate so that the tissue again can have oxygen and Then finally they start the process where the cells can move together and close the wound So we don't have these gapping open wounds So you can imagine that these kind of inflammatory cells in a tumor that could actually be hijacked to promote the tumor growth these signals to make cells spread Proliferate or make new blood vessels come in would make the tumor do the same and the signals that can make cells move Maybe able to make the cancer cells spread and indeed that's what happens So what we found was that these inflammatory cells that are coming into the tumor turns out to be the bad ones They're not killing the cancer cells They're promoting it and making it harder for the cancer to be killed by chemo what you're seeing here is The tumor in a normal mouse and we give it chemo and you can see it's not actually shrinking It slowed down a little bit and then after just a few weeks It continues to grow these tumors become resistant to the therapy very rapidly. It doesn't work very well But here we have taken away the inflammatory cells through a genetic trick And so now they are no longer coming in and you can see that the tumor remains the same size for a longer time So this is an approach that's now taken to clinical trials and people We are trying to understand whether this could actually help patients have a longer response to their chemo therapeutic treatment Now what I've shown you so far is work We've done in the first in the primary tumor and the breast tumor in this case and how we can watch the cancer cells Go into the tissue and interact with the immune cells But one of the biggest problems in most types of cancer is not the primary tumor in many cases We can cut that out. We can irradiate it But what we all worried about is when the cancer spread and for breast cancer patients It's about two out of ten that that eventually happens. So we wanted to understand how did the cells get there? How do they get into the new tissue for instance along and when they do what is their interaction with the immune cells in that new tissue? So to do that we wanted to again do Do imaging but to do imaging in a in a long is quite difficult as you can imagine The the lung is moving. It's breathing the mouse. You will be able to hope so if it's live imaging So with a collaborator at UCSF in San Francisco We designed these windows. So these are 3d printed plastic windows and they are put in in between the ribs of the mouse And you put the mouse on a ventilator So this is quite involved Surgery as you can imagine and through this little glass hole We can now do microscopy in a living mouse in the long and see what happens when the cancer cells arrived to the long So this is what you're seeing here in red We have some of the cancer cells that had arrived to the long and then we have the inflammatory cells in green And now we wanted to see all the other cells in the tissue So we injected a dye in blue that would make the DNA of all the cells turn blue so we could see them But this is what we saw You see that we have cells here all these dots is an individual cell But staining glue the way you would expect but around this one cell We are seeing not a dot, but a smear or a cloud of DNA signal So it was very mysterious in the beginning. What was going on here? What is this cloud of DNA? As it's to try to understand that we used a different technique Electron microscopy, so this is the image that you have seen on the surface of the on the front page of the program for tonight This is a normal neutrophil in an electron microscope and This is a neutrophil that has taken its DNA and made these hair strings or spider web kind of structure So it's coming out of the neutrophil and you can really see how it looks very different This is the structure that we are staining in the living microscope and we can follow. So what are these peculiar structures? Well, this is you saw before how the neutrophil could eat bacteria But some of the pathogens that we are encountering are too big to be eaten This is a aspergillus yeast and you can see it's much longer than any neutrophils So here they are clumping around their aspergillus trying to eat it and they can't So what they do instead is they take their DNA and you'll see in the moment the DNA light up in bright orange as it comes out of the cell And they take the DNA and they use the DNA as a spider web where they put in the same toxic enzymes It's normally eating the bacteria inside But now they are on the outside and they can attack this yeast on the outside So what we found was happening in the tumors was that the tumor cells are hijacking this mechanism They come to the vasculature to the blood vessels in the lung and then they send a signal to attract the neutrophils These particular inflammatory cells and then they give them a second signal a signal that tricks these cells to think that there's a bacteria or Yeast so that they form these Extracellular traps neutrophil extracellular traps and they have in them the enzymes and these Enzymes these proteins make small holes that makes it possible for the cancer cells to get into the tissue and Start to sit there, but they do more than that We also found that they stimulate the cancer cells to start divide and make more and grow faster So if this was of course discovered not in cancer originally But in inflammatory diseases people were trying to understand how our neutrophils combining a different bacteria different yeast And one disease that has problem with many many infections is cystic fibrosis And these patients tend to have infections that they can't get rid of and the Bacteria and the yeast trigger all of these nets to form in the lung So there is a drug that the patients can inhale to dissolve the nets in their lungs So they can breathe better and so we wanted can we use that same kind of drug to prevent metastasis in our mouse models And we tested it and It didn't work the drug is called DNAs So we were thinking for a long time. What can we do to make this better? What is the problem? Why is it not working and it turned out that the problem is that the DNAs is only active for 30 minutes after you inject it So you inject it into the patients. It's active and then It stops working. It can't inject the drug every 30 minutes. That's just not possible So what could we do about this and I remember giving a talk about this at Dana Fabra Institute And after my talk one scientist came up to me and said I think I have a way to solve your problem We have made something called nanoparticles and when we put things on nanoparticles They stay active for a longer time. Would you like to collaborate? so I said yes and He made nanoparticles that were coated with this a drug DNAs So these are the naked nanoparticles that are given to the mice and you can see these mice have metastasis all of these Areas are pointing to regions in the lung where we have metastasis. There's lots of metastasis in this mice This is an example from a mouse that had the nanoparticles that he designed and you can see that the lungs looks almost normal This worked really well in our mice now The next thing though is that for many of the breast cancer patients it's hard to know when they are going to get the metastasis When patients are diagnosed most of the breast cancer patients do not have metastatic disease at least not that we can recognize clinically But we know that many of them will have cancer cells that have already spread somewhere else in the tissue So they may sit in the bones in the brain in the lung or in the liver What we don't know is who's gonna recur when and where? It's about again as I said two out of ten that have this recurrence So where when and why is a big question So to start to try to understand that we developed a new way a new mouse model to look at what's known as Dormant breast cancer This is such a model and you can see a cancer cell here sitting again in the lung and There is again these inflammatory neutrophils sitting around it We also have the DNA die for now. We're not seeing a cloud This may be the most boring movie we have ever acquired Nothing is happening the cancer cells sitting there and the neutrophils seem to come and sort of look at it And then go away so you can see how they are swarming around it But then they go away they don't do anything and the cancer cell doesn't do anything nothing happens This is a sleeping cancer cell But as we were one looking at this movie we were wondering why is this cancer cells sleeping? Whereas the other ones were metastatic What would happen if now there was an infection and these neutrophils were forming again? Neutrophil exocellular traps, but it was not the cancer cells that were reducing it, but it was a bacteria So So that's a question what happens if there's an infection in a mice that have one of these sleeping cancer cells So to test that we took now Something called endotoxin which is a component of the bacterial wall and it's one of the drivers of what's known as sepsis It's quite dangerous But you can get it to mice to mimic a lung infection and so that's what we've done here This is a mouse that just got saline as a control and this is a mouse that got endotoxin And now we're just imaging what happens to these neutrophils Over here, you can see nothing much happens. You have these black spots. That is a nice airways You have the the DNA in the nucleus and you have the the neutrophils moving around to see if anything's going on And nothing's going on but over here after endotoxin Inhalation you can see now there's more neutrophils They look much more flat and you can see there's also stronger DNA signal They're starting to make nets and we have in red a special trick where we can see where is an active net So whatever there's an active net it turns the area turns red We have the same trick over here, but there's no net. So you don't see a signal. It's all black Now so what happens when we activate these nets? Well, these are our control mice. They have the cancer cells sitting Few hundred cells are sitting in the lungs and doing nothing. This is eight months out We've looked at them and you can't see anything These are the mice that got endotoxin three weeks after they had this Experimental infection all of the mice had metastatic disease in the lungs many of them also had it in the bone This is what the lungs look like. It's all over and these mice are dying within three to four weeks And these are the mice that we treated with the nano DNA is particle that we generated You can see now three out of five mice and that turns out also in bigger numbers about 60% of these mice They do not get in a metastatic disease, but they still have the cancer cells sitting there sleeping and those that do get it It's growing much slower So we're very excited about these results We're thinking about how can we? How can we apply that to the clinical situation? so some of you may think well, what's is this only in breast cancer cells and We've already tested it in prostate cancer and pancreatic cancer models in mice and there It's the same thing if we have sleeping cancer cells in the lung from prostate or pancreatic cancer They do not that they are activated by these nets and we can inhibit it by targeting the nets But it's in mice. So what about people and that is the main thing We are trying to understand right now do these nets awaken the dormant the sleeping cancer cells in in people We don't know but we know already than in people You can have nets after infections after trauma after smoking and after obesity So all of these situations are associated with higher levels of nets in the blood And so what we're trying to do now is to find out if we detect the nets Does this person have a higher risk of having the cancer coming back? And so that brings me to to the end really starting to think about which patients might benefit from this net targeted therapy And I want to mention two people that are a major inspiration to me This is our beloved miss Debbie from the Cold Spring Harper daycare center She's brought up most of the kids here from the lab and she passed away last week from metastatic ovarian cancer and we We miss her dearly and of course we are speculating ovarian cancer that is so aggressive Through the nets play a role and we don't know what we're gonna start trying to find out This is Dale cup. That's my brother-in-law's mother and she is one of the people I really have in mind when I'm thinking about where could this go So she had had a neck cancer and she was treated successfully with surgery So the primary tumor was removed and then three years later it came back and when it came back There was no sign of metastatic disease. So she had surgery again, and then she was gonna get chemo therapy but right after the surgery the cancer spread dramatically metastatic all over the body and the chemo only worked for a short time and Unfortunately, she passed away So I've spoken with clinicians since and they see that in patients. Some patients have a very dramatic Recurrence of metastatic disease right after a treatment So what we are wondering is did she have a lot of excess nests nets? Can we detect it and would she be kind of the patient where we could prevent the metastatic disease by targeting the nets? simultaneously with surgery So with that I want to finish by thanking the people that did the work a Lot of the work you've seen today is done by jungle Frank is a postdoc in my lab with the help of many people in my lab Included David Mario Li Zhuang Emily's and Laura. I Also want to acknowledge all of my collaborators. So at Cold Spring Harbor I had very many collaborators help us really develop this and tested it in many different models including Johannes yay, that's helped us generate a way of targeting these nets and Dokfein and Lloyd trodman that helped us test it in prostate and pancreatic cancer Outside of Cold Spring Harbor. We have many collaborators helping us to move this forward Max criminal as I mentioned this the one that's really helping us being able to image in the long it is really as hard as you might think and Then we are studying These nets in humans and in different types of inflammatory diseases with Ken Pinkerton and Scott and Jill Hamilton Reese Michael Goldberg is the collaborator Dana Faber that generated these nanoparticles and Sylvia Adams You're gonna hear from in just a moment and so with that I want to thank you for your attention and I'll be happy to take questions Thank you We'll be doing some very short Q&A right after Michael is talk here And then dr. Adams will speak and we'll have a short Q&A then and then a Q&A all together So so it'll be short, but we'll have time for a couple questions Do benign tumors ever convert to cancerous tumors and vice versa and what is the similarity between a tumor That's non malignant and a malignant tumor. Is there a similarity? That that's a very fundamental question. So yes benign tumors sometimes to convert they acquire additional mutations It is rare to see the opposite But it may happen it has been shown to to occur in mouse models But it's much harder to prove an inner patient The difference the definition is really whether or not the cancer cells is starting to to spread You can see whether it's trying to leave the tissue and once it's trying to leave the tissue Whether or not it's done it successfully. We consider it malignant What is the difference between net Therapy immune therapy and targeted therapy the drugs. Can you explain the difference? So the targeted therapy is usually going after a specific target So that would be often a genetic mutation and the cancer cells. So people have discovered Mutations and they have found rocks that are specifically directed against these mutations for the nets It's specifically going through this this DNA scaffold and trying to dissolve it or target The enzymes that are on it so that the nets can't be functioning and immune therapy is is Functioned by stimulating the good part of the immune cells. So instead of having these bad immune cells that are Making the tumor worse. You are stimulating the good immune cells that you're gonna hear about in a moment to make sure that they work better one right here Hi, um, is it possible for chemo to trigger the growth of a dormant cancer cell? So there is some some data suggesting that chemo can have disadvantages for Uncertain situations and some of the chemo also works on the immune cells Whether that's a good thing or bad thing comes back to this question. Is it a good or a bad immune cell? We are targeting I think although chemo is one of our oldest types of drugs. We don't fully understand how it works Beyond just the cancer cells. How does it work on the agate? organismal level in the whole body view and that's one of the things we certainly are trying to to understand better Hi, is there a risk for DNAs to attack regular DNA in other cells besides neutrophils So we all make DNAs already. It's we have our own DNAs that is targeting some of these floating Nets even and and it's when we look at the the presence of nets that are spontaneously forming They're not very long-lived because of our own DNAs With the nanoparticles we are hoping that it doesn't get into the cell But but you're right there is always safety concerns and the best way to do that is is to To do the more animal experiment more carefully targeting the safety of that and just finding out the safety of that and then ultimately dose escalating in Patience. All right, we'll move on to dr. Adams. Thank you, Nicola Thank you. I always like hearing Nicola always tells a great story with great movies And so Nicholas research is a good example of the type of of the power of how basic research can inform Clinical research and now we're going to hear store from Sylvie Adams about her research and doing clinical trials and breast cancer So dr. Adams. Thank you. Good evening everyone so it's a pleasure being here and I'm very excited to collaborate with Nicola on understanding really the interaction of the host immune system of the patient with cancer and how one could potentially Harness this interaction to treat cancers and prevent them So the topics that I would like to cover Initially, I would like to give you an overview of the tumor micro environment And and show you the different players on the field that can be Promoting cancer growth or actually inhibiting cancer growth and then I will focus on two Cell types one is macrophages that actually can also similar to the neutrophils that we just heard about enable invasion into blood vessels and metastases and They play an important role that we have identified already in breast cancer as a prognostic biomarker and From our last weekend's a large clinical oncology meeting in Chicago that you probably heard about There will be there was a plenary session on the Taylor x clinical trial Which I will briefly mention to you because macrophages are actually part of that assay and how it affects our Knowledge about cancer prognosis, but also how it guides us in terms of what therapies to use for the patient And the second focus will be on lymphocytes. These are our killer cells and can actually effectively kill cancer cells And how they are important for prognosis for patients and also how we can harness them and make them stronger in our treatment of programs so Mikaela actually already showed you the slide looking at a cancer under the microscope and Until you know several years ago our pathologists when they did look at the cancer. They just saw this is the the very Very comprehensive tumor micro environment But they mainly looked at the cancer cells in here and they gave us on the pathology report Information about how those cells look how they are differentiated what receptors they express And they really didn't talk about much about what is in the stroma. So the stroma is basically all the supporting substance They only gave us at this time if there's any cell death How deeply the tumor invaded and if there is also invasion of cancers into the blood vessels? however, the Significant part of the stroma is actually that it can help Either cancer growth or it can help to stop cancer growth And these are just a few of those components that we know to date. They are inflammatory cells all these floating cells in the circulation Some of which can either promote metastases as we will talk about and some of which can actually help fight cancer So so there is a very heterogeneous infiltrate into more cells that can be Harnessed for for our therapies and this was just a very early Paper showing that if you look at that stromal infiltrate by gene expression analysis And you look at good stroma cells, which we call here cluster set one that patients who had this cluster Did very well they lived without cancer occurrences But patients who had in their tumors immune cells that were belonging to this Inflammatory subtype that actually had significant progression recurrence of disease and had death so this was one of the Initial papers to tell us that it's important to look at the stroma not just at the cancer cells because cancer cells would be similar in these patients So let's talk about the macrophages And this is a busy slide, but I guess if you can look at this black window you see Three types of cells very similar to what you saw in the prior talk The cancer is growing here and kendo cells are in red the blood vessel is in blue lined with endothelial cells and Macrophages very similar to the neutrophils are also in this complex and we call this to T. M. E. M. complex And what happens is if you have a macrophage very close to the primary cancer It can help invade cancer cells into the bloodstream and lead to metastases and in a clinical study This shows again survival of patients is affected by by the likelihood of metastases But most importantly I want to bring your attention to the oncotypes Oncotype DX assay, which is the one that was presented at ASCO last week and that includes one gene That actually means macrophages So these are all the genes in green that are contained in this Panel and this is basically after a woman undergoes surgery for breast cancer We use the tissue not only to look at the differentiation grade Receptors etc. But also to send this tissue for a special molecular test called the oncotype DX 21 gene assay So 16 genes are cancer genes and then there is five housekeeping genes Or reference genes and one of those cancer genes is called CD for cluster of differentiation 68 and that is a macrophage marker So the the company that established this assay then put all these genes together and came up with a formula That culminates in a recurrent score. So when we get this score back We show it to the patient and said you have a recurrent score based on your Tumorous molecular analysis of 17, which means that you have a XYZ number of chance of recurrence in the next 10 years and Can we use chemotherapy to bring that down or not? That is determined by the category of this so the category The the subsets are low-risk categories intermediate and high-risk patients And when you are in the lowest category, that means your chance of recurrence is very small and you just need hormone therapy If this is a hormone positive tumor in the high-risk group, you know that chemotherapy in addition to hormone therapy is important But in the intermediate risk, we did not have an answer from a large clinical trial until basically one week ago So in this trial, this was You know a large plenary session Discussion and this was also in the news afterwards do women need chemotherapy And we're very happy to say that this assay and the results in this intermediate group spare women from chemotherapy that we often give after surgery so this is was dr. Sparrano's presentation and It looked at a trial called Taylor X So we wanted to tailor the therapy to the patient and her tumor based on the 21 gene assay and This trial enrolled about 10,000 patients. I think we enrolled about 30 at NYU and this was open at hundreds of sites and 10,000 women got enrolled patients who had a low risk which is up to 10 in this Trial we're just given hormone therapy for five years typically women who had high risk recurrent scores We're given chemotherapy and hormone therapy But in this middle group where we didn't know if chemotherapy can be helpful. We actually randomized patients. So that means They were randomly assigned 50 50 chance to chemotherapy yes or no In addition, everyone got endocrine or hormone therapy So arm B is patients who only got hormone therapy and an arm C is patients who received chemotherapy on top of hormone therapy and you can see it's over 3,000 patients in each of the arms and This was just more about characteristics of this patient population So these are women who have hormone positive breast cancers that are lymph node negative So no axillary lymph nodes are involved and had relatively small tumors 1 to 2 3 centimeters The average age of women was 55, which is our typical population with early breast cancer and a Lot of women were a perimenopausal at this age group, of course So here is the data and this was probably one of the most exciting talks. I've said in And you can see that the brown or bluish and yellow lines are really identical So this means in the first graph here that invasive disease-free survival the chance that this cancer can return Either in the same breast and the other breast anywhere else in the body is identical between the two groups meaning that chemotherapy is not needed and The same holds true for distant relapse free intervals meaning that cancer returns outside of the breast area Such as in bone as we've seen pictures before or in the liver that is again identical and survival was also Perfectly identical. So this is what we like to see in terms of highest clinical evidence in a randomized trial This gives us level 1 evidence that we can actually now Not recommend chemotherapy to the majority of our patients after breast surgery Of course, there's always a caveat and when you look at subset analysis of a negative trial You find some subgroups of women who may benefit from chemotherapy and that unfortunate subgroup is women Now under the age of 50 where depending on the recurrence score There may be some benefit to chemotherapy. So that is continuing to be discussed on An individual basis with each woman in the clinic so this was the interesting thought about Macrophages how they promote distant metastases and if we actually with chemotherapy can bring the patient back and have Higher cure rates. So this speaks to the to the part of tumor promotion that you can see metastases here Coming through the help of macrophages and I hope I have neutrophils on here, too. Mikaela forgive me if I don't So now let's talk about the second Alternative is when CD8 cells or killer T cells lymphocytes can actually kill tumor cells and therefore Inhibit the growth of cancers. This is our second some topic and and Similar to what the prior speaker had discussed sometimes you see more immune cells in a cancer and cancer cells And this is a perfect example and we call this example Actually a lymphocyte predominant breast cancer because you have more lymphocytes here and cancer cells and here those those Bluish areas are cancer cells cancer cell nests. I would call them but surrounded these are all lymphocytes all these small black Tumor cells are lymphocytes. So they are there to trying to kill the cancer However, cancers grow despite that so there must be a reason for it And I will tell you later about PD1 and its pathway in a way that cancers Shields the attack from those killer cells but first how do they Do they matter these lymphocytes in the tumor and and I'm mainly going to talk about triple negative breast cancer or TNBC That is one of the most aggressive sub types of breast cancer as you may know because there is no Estrogen receptors or her two receptors that basically would offer you targeted options So you are stuck with chemotherapy as the single modality for this cancer. They're more aggressive They have higher recurrence rates. They flicked younger women so we definitely need better therapies for this group of patients and When you look at these different breast cancer subtypes in a very large gene set You can see the basal like or triple negative breast cancers here that have Probably in about 20% of those tumors have lymphocytes In in the tumor and it's the highest number Compared to the other breast cancer subtypes. So here you have luminal a cancers which are mostly estrogen driven hormone receptor positive tumors and There lymphocytes don't matter actually which is interesting because macrophages seem to matter more in that subtype So it's really subtype specific. So looking at the infiltration of triple negative breast cancers with lymphocytes Here I show that they are highest and they are prognostic which is really important and I will show you that data set This is work that we have done one of the largest trials in this country 10 years ago was giving women chemotherapy after surgery When they had triple negative breast cancer and we went back and looked at those archived slides from the initial diagnosis and we counted lymphocytes in the tumors and You can actually see that each percent increase or 10 percent increase of Lymphocytes in the tumor Predicted a much better outcome for the for the patient and it was so dramatic that you can actually see here It reduced the chance for death for that woman by 19 percent So each 10 percent increase some women had zero lymphocytes in their tumors other had 60 percent and you can see here in this Simplified schema that women with lots of lymphocytes or lymphocytes predominant breast cancer had excellent survival Where's women with no? Immune cells in their tumors had very poor outcomes. So this was the first evidence that actually impressed cancer the immune system matters and This was basically from untreated patients who then after surgery got standard chemotherapy No immune therapies just standard chemotherapy and radiation and they did better if you already had a pre-existing immune response to this cancer so this was then also shown in many other studies and in In summary we actually came up with guidelines how to score these lymphocytes in tumors so that they can be You know evaluated in clinical trials or in even in practice even though it hasn't yet Fully gone into practice But the other the other thing that this is very exciting about is that if your immune system predicts outcome We can probably twist some things to make outcomes better So I talked about the the word PD-1 and PD-1 and that is if you have lymphocytes in the tumor They may actually have initially worked, but then they are calmed down They're there are no longer active and trying to kill cancer and that is because they can upregulate certain receptors on their surface molecules that actually slow them down and That is one of those receptors is called PD-1 or program death receptor that receptor comes up if the lymphocyte sits in the cancer area And the cancer brings out these shields called PD-1 that induce PD-1 expression on lymphocyte So this is basically a very negative signal for from the immune system to calm down the immune response against the cancer Because this cancer was very smart and outsmarted the current response What you do is you take an antibody and you block that interaction and you can then Restimulate those T cells or lymphocytes that are in the tumor micro environment to really do their job and finish kill the tumor So this is very very exciting and based on our initial discoveries that breast cancers are immunogenic or at least in triple negative breast cancer They are Companies that have these compounds were interested in studying them in breast cancer So the these are some of the first trials that were presented a couple of years ago now That gave us lots of hope for this field and these are women who have metastatic breast cancer where The tumors are located in lymph nodes and liver and lung and other organs and they are with chemotherapy not curable In fact, despite chemotherapy the survival rate is about one year and for those patients so in this treatment in these treatment trials what we saw is that the tumor volume and this is like zero where you Start out with the baseline volume of the tumor when you enter a clinical trial Was in many patients actually decreasing just with this hormone with this immune therapy that blocked that shield between the T cell and the cancer cell and most importantly Some of those responses were adorable. They stayed in this Response rate for a long time Three years out now. We have patients that were receiving these drugs and they are still without any detectable cancer on scans and That is exciting chemotherapy does not do that and that really encourages us to Continue to search for better treatments and combination therapies because in this trial We only saw 18 percent of women respond and in the subsequent trial, which I actually led Which was a global global trial in metastatic triple negative breast cancer We saw that it only really helps a very small subset of patients These were all women with advanced triple negative breast cancer that were not selected by PDL one status Which is something we look at often in the tumors now And these are the waterfall plots meaning that if you go down you have shrinkage of your tumor if you go up. Unfortunately, it is growth and progression so only very few women had complete shrinkage of their cancer and What we call usually partial response around 30% Some patients had but the good news and this in this study also is that once you had a response Even though small numbers of patients they could be durable Again, we could have women three four years on these drugs without any recurrent disease But certainly the numbers are small so we like to Increase them and make them more applicable to other patients as well So what we did actually is design trials that combine these immune therapies with chemotherapy Which are the main? Stay of therapy in triple negative breast cancer and and that allowed us a couple of things number one Is it kept patients stable because as I mentioned before these are very aggressive tumors? That without therapy very quickly women become very ill So chemotherapy in addition to the immune therapy allowed some stability It also shrank tumors which sometimes allowed less immune suppression that is coming from the tumor and We learned over the last decade or so that some chemotherapies can actually promote a healthy immune response very Very kind of intuitive to what we always think that chemotherapy does kill your immune system It's not completely true depending on the doses the scheduling the sequencing of therapies it can actually promote an immune response So this is a Trial which I'm very proud of because this was the first chemo and immunotherapy trial in this country that I led and Here you can see that the waterfall plot is incredibly much better than just the immunotherapy alone trials that we had done before and We also showed that we look at the word response rate here overall response rate that patients who just had Diagnosed had been diagnosed with metastatic breast cancer had the highest response of 54% so nearly half the patients in that arm responded But when you go to later lines if they already had chemotherapy in the metastatic setting then response rates would drop more But the other important thing is that while this trial was designed to initially combine chemotherapy and immunotherapy We only mandated a four cycle Treatment of chemotherapy after which we dropped it often. So women got to Enjoy a year or two years off chemotherapy And I mentioned to you before life expectancy is usually one year with chemotherapy. So this was major Enjoyment in the clinic by seeing women do well hair growing back etc and Excitingly for me is that Survival curves that we've seen in many cancers now with immunotherapy where there is a tail of 10 20 30% of patients that still are surviving years later that we kind of saw this too So this is now going out to two years to data And you can see there is a substantial number of patients Alive which is not what we see with chemotherapy alone So I am very happy about that Of course, we are not where we want to be with having every single patient respond But that's why we need much more research such as what Mikala is doing here to understand other factors that that participate not just lymphocytic infiltrate and how we can Improve that response, but also what the other components in the microenvironment do so this is a very dear patient of mine who you know had an incredible response and Always makes me smile when she comes. She is much younger than me in her 30s. She's a physician and She came to us. She was referred for the clinical trial that we had at NYU at the time several years back from Memorial and she when she came to us she had Diseases, you know a body PET CT and these are lymph node metastases and these are long long metastases and She had Interesting findings on her skin because after the first two treatments on her skin the lung lesions all went away, but then she developed new lymph node lesions in her chest wall and When we see this on chemotherapy we say we have to stop chemotherapy immediately But in immunotherapy where you can actually have an immune response inflammation and and so on You may see new tumors pop up that are not Worrisome and you actually continue therapy. So we luckily did for her and after two more cycles all of that disappeared We were able to drop her chemotherapy, which is a taxing which can cause over many months neuropathy Or you know numbness of fingertips and she is a pediatric Intensivist where she actually needs her fingertips to put IVs into babies. So we dropped the chemotherapy and she's been since Completely without any evidence of disease and she doesn't even count on the on the plot of Tumors that go down because of this new finding on the second scan. So officially she is a Progressive disease patient, but she really had tremendous benefit from from therapy And and so this trial that I explained to you which was the first chemotherapy immunotherapy trial gave rise to the largest trial Done in this country now, which is hopefully going to get results either this year next year that Is a trial looking at survival outcomes in women that have newly diagnosed metastatic disease that is triple negative and that trial has completed enrollment in In the world actually was mostly done outside the US These are some examples of Combination therapies that are now not just in a metastatic setting but also in earlier breast cancer settings So the the one you may have heard about last year was called the ispy 2 trial Where immunotherapy was added to chemotherapy before surgery and you read out at the surgery time How many cancers disappeared at that time and it was three times the Rate when you added immune therapy to it. So these are quite remarkable Data and I think it really Invigorated not just the T cells but also our field and in truly believing that that this will work Hopefully for many more patients. So And you may have also heard on NPR and the news lately So that's why I'm adding this case report from the National Cancer Institute of a woman treated Not with triple negative breast cancer, which is probably the most responsive to immune therapies but hormone positive breast cancer who had metastatic disease and the group there Did in very sophisticated laboratory? Analysis they took a patient's a piece of the tumor sheet multiple metastases But they took one piece they isolated these lymphocytes these T cells from the patient's tumor and figured out which ones recognized new Mutations on the tumors and then enriched the product before giving it back to the patient in billions of cells so basically they they picked out the good killer cells they Enriched them and then infused them back into the patient with a complete clinical response And that was the the picture. This is a CT scan. So you have the sagittal view where? Sorry the coronal view where you have these are the reconstructed breasts here But there's a large soft tissue mass close to the heart here that is gone after therapy And this is the the liver here with multiple Metastases in the liver. They're all gone with therapy, but to say That this was just this we infusion of lymphocytes is is incorrect because the patient got lots of other therapy So she got before the infusion of TILS. We call them tumor infiltrating lymphocytes She also got chemotherapy to kind of kill down many other Immune cells she had and then she got this boost of tumor reactive lymphocytes Followed by PD1 drugs, which I mentioned to you before so this was a You know a celebrated victory because it has shown home on positive breast cancer patients can respond similar to other cancers and You know just because I had to promote my own work. I Wanted to show that we published actually years ago a patient who had a fantastic response to immunotherapy and I apologize if For the pictures, but this was really and very impressive breast cancer. This was a woman who? Came in with already widely metastatic disease She had calcium that was leaching out of bones because of bone involvement She had destruction of bones in the sternum involvement of the lung etc and we gave her chemotherapy with Avastin, which was approved at the time and then later on added in micromod, which is a topical immune stimulant to her breast Which is kind of supposed to jump start the immune response against the tumor that is still in the patient And later on she got home on therapy and she really cleared everything There was no more cancer left on any scans and many years later. She was Cancer-free and we were able to actually go back Draw blood from her later two years later and then compare it and we showed that just a simple application of Topical immune stimulators onto the tumor could initiate an immune response against cancer that then was just amplified through regular standard therapies, so I Wanted to leave you with some concluding thoughts on here and that is that the Immune response is crucial in in the outcome for patients and In the first part of the talk you heard that neutrophils and also from my talk that Macrophages can actually facilitate spread of cancer into other organs and therefore Usually give you a poor prognosis, but on the other hand you also have lymphocytes or CD8 or killer cells That can kill tumors and have a much better outcome for patients Talking about immunotherapies and breast cancer What is most exciting are these durable responses that we see in a subset of patients with these drugs that target pd1 and pdl1? however Responses are still low probably in the 5% range or 10% range, but They should be much higher So combination therapy is likely where we have to go next and that could be multi Immune therapies or radiation with immunotherapy, but you know we have Pioneered the chemotherapy combination, and I think that is a very important Partner to to their for therapies and then I think we still need to to do much more in understanding the biology of The micro environment of the cancer and the responses of the of the patient To to really cure more patients, but anyway, I wanted to leave you with this and The thank-you slide didn't make it onto the talk. I'm very sorry for that, but Mikaela's talk reminded me So I'm very grateful to patients who participate in our clinical trials the research team that is incredible in keeping things in Order the referring physicians, you know, I have to tell you in New York City I'm very proud of our colleagues in all centers We when we for instance have a young woman who has metastatic triple negative breast cancer We call each other and ask do you have a clinical trial to participate in because we know chemotherapy is not the choice So we do send each other patients for for certain trials and that is very very helpful and I'm also very grateful to my own team of seven oncologists Who you know only see breast cancer patients our radiation docs our Surgeons pathologists and so on and then of course the funding agencies such as the NCI department of health and many other Good groups to support this work because it's you know, not only pharma that should make progress and and lastly collaborators such as Mikaela and then Nina Bartwosz at Sinai who are really close friends and Good colleagues So thank you We have time for a couple of questions first for dr. Adams, and then we'll do a general Q&A with both dr. Adams and dr. Agablat Chemotherapy drugs are they similar or completely different and how do you decide? What drug is used for what patient? That is a very good question So for Curative intent therapy meaning early on in breast cancer We use very standard regimens that have been designed through very large clinical trials like the one that I presented Where you have multi drug regimens But for later stages some we usually use single agents And we still don't fully understand their impact on the immune system, and I think we are currently Working on that so we are having several Protocols open that we ask for tumor tissue From patients on therapies on standard therapies because we really want to understand how chemotherapy for instance Impacts neutrophils macrophages and so on So in the curative setting yes, it's all It's all cookbook from established trials, but in later lines It's still a lot of unknown because they're not great So so most of the drugs were actually Discovered many years ago decades ago. They have mechanism of action such as just adhering to enzymes in cells that inhibit the repair of these cancer cells when they have Any insult to them some others have just blocking reproduction of cancer cells by by adding Particles to their DNA so it's really toxins that That are you know used for Treating cancers, but there are different drugs for different cancers too So we don't use for instance drugs that are used in lung cancer or vice versa If someone was being diagnosed as metastatic tomorrow, what would you advise them to do? I? Think that's some you know pretty simple even though it's not a simple thing at all but it is to really search for doctors and trials because We are not yet there in terms of curing metastatic breast cancer So I think I would look very aggressively at clinical trials, and that's what the NCI designated cancer centers do Demand it is to really Have good trials available, and I think if you find the right oncologist, they will help you in on this I was very impressed with the those last Pictures where you showed the breast change dramatically over a relatively short period of time That was a topical application of Of a chemical rate So the topical was actually given only for eight weeks At a time later on when the cancer had already somewhat stabilized initially was chemotherapy and Then the topical later when she had stabilized disease and then later on it was just hormone therapy well the the reason why I couched that question is the real question is chemo surgery and and Radiation Seem to have very big downsides and they might actually Progress the cancer more. I mean unfortunately. I have the experience of losing my first wife and To cancer and the chemo I Think just aggravated the whole situation now I think it's the technology that has proved itself not to be very good. Are you on that? Same page so I think chemo Can sometimes be detrimental and that's when patients are weaker and the cancer has widely progressed and that is important to discuss What are the benefits of treatment versus the risks? But an early breast cancer meaning that it's still confined to the breast and lymph nodes locally It is a definitely changer in the cure rates. It does help us cure patients lots of them so I truly believe still in that triple approach of radiation surgery and Chemotherapy although there are now trials ongoing. Can we actually skip surgery because our chemo therapies are pretty good And we can probably skip surgery in some patients and those are trials that need to be performed before we can say we can do that I Don't know the answer that question. What's my success with surgery in in early breast cancer? So so I think my collar brought that up right that if you do a lot of abdominal surgery And yes, you can stimulate wound healing processes that can actually facilitate metastases. Yes, that is still a possibility on the table and interestingly for instance if you take antibiotics during immune Therapies you can weaken that response to immune therapy So it's because the gut bacteria that are being killed by antibiotics for the flu or for for any kind of infection or antivirals Can actually make your own immune system less susceptible to to these therapies. So yes much more to understand I think for muscle invasive bladder cancer The standard is first chemotherapy and now we are curing lots of those patients actually with immune therapy to bladder cancer It's one of the best tumors to respond to yes, but now it's it's prime time for bladder cancer actually Like to invite both of our speakers up to the chairs up here will do a general Q&A for both of them is their research that is presently going on to Discover how and why the body makes these different types of immune cells and to encourage the body To make the immune cells that would be helpful to kill cancer cells Yeah, absolutely That that's there are many of us that are studying What are the normal stimulates that are inducing the different types of immune cells and how to boost to them? So that's a very active field of research Our similar response rates being seen with each of the PD1 PDL1 blockers run the development now To do what we were talking about the relatively modest results Yeah, I think they are they're very similar, you know across the the board slightly Actually just the side effect profiles are also very similar. So Yes, hi. Hi, um So which of the treatments is better for? Beating the cancer They immune the net or the hormonal like which is better. Do they all have faults? I Think you saw an serious trial design that it's all about combinations. I think When we are targeting the nets even in in mice We get some good response in some of the mice but not in all of them and it's telling us that we need to combine To do multiple approaches, but that's that's my take And you know to encourage that research It takes women to participate in trials where we actually obtain blood and tissue from from patients and I'm really grateful to women in our Combination trials with chemotherapy and immune therapy. They are willing to give us serial biopsies of tumors to really study the changes of each of the components of therapy and Also, I think to go into trials that are basket trials where you have You know more suitable therapies for patients with certain Questions is important. I think endocrine therapy is still wonderful for hormone receptor Sorry It it depends. So most of the combination trials now that are being designed are looking at biomarkers in the tumor You know, do you have this protein that is expressed and then you can enter a trial that has Certain drugs targeting that So I think in the future, we'll see more of those directed patient specific arms of trials And maybe I can add to the nets. It's not all all types of breast cancer cancer that we are seeing the net's end It may not be all patients that have infection all types of infections that cause these nets And though that's why we're focusing on developing assays so we can see whether or not there are any nets So it's it's combinations and finding whether or not this particular area Target is present in the individual patient Hi, my name is Kevin and my question is in recent literature a high-fat diet has been shown to affect gum microbiome and promote angiogenesis and tumerogenesis in an array of cancers from breast to prostate to cancer prostate cancer to colon And with the trials of cancer the last thing you want to do is go on diet But do you think that reducing the fat intake in cancer patients could reduce angiogenesis and then inhibits immune cell access to tumor cells and thereby significantly reduce the impact of TMS on the effectivity of chemotherapeutic agents So I think that the High-fat diet is is doing things both to to the gut bacteria as well as two different immune cells So it's a pretty complex question at this point. What what is going on on the different immune cells? But there is strong evidence that things are going on including on the neutrophils. So this is a very active research area And I actually want to mention also that trials are now being designed that look at fecal transfers So stool of some patients who have great responses to these therapies Given to patients who didn't have responses to therapies who may then actually develop responses that's been shown in mouse models to work really well and we use it also for Infections often in the colon, but that is the next wave, you know to really modulate To hit additional targets when we give these therapies Hi so in the case of Macrophages and neutrophils are the cancer cells actually utilizing the immune cells Processes that are already going on in order to perform these or are they actually signaling to The immune cells to perform the process for them. I think it's a bit of both but We are starting to know a lot about the signals that the cancer cells are using so in in the case of Our work we've seen cancer cells send out the same kind of signals that would be send out if there was an infection To attract the macrophages and the neutrophils But they're also sending out signals to to flip the switches on these cells both macrophages and neutrophils actually can be killer cells But they the tumor cells send out the signals so that they are not We'd be starting to know a lot about these signals and trying to target them and do that in combination with the With the drugs that activate T cells I Think that we've seen that that is possible It I mean, it's not possible in all patients But we know that it's possible and so now that the next wave is to find out How do we make that happen for for everyone or for the majority? And I think the discoveries in the last couple of years for hormone positive breast cancers have been quite practice changing so There are new drugs and you probably see those on TV all the time. They're targeting certain Points in the cell cycle and they're called CDK inhibitors and you probably saw eye brands and all these other drugs on TV and When we add those to regular endocrine or hormone therapies for patients who have metastatic breast cancer They they have no cancer worsening For up to three years in their first treatment line and we used to know that the hormone therapy alone Probably kept them Well for one year and then we had to switch to the second Regimen but now we can add it to the first one and it's from one to three years Same with targeted therapies for metastatic breast cancer the addition of a pertusia map added Life expectancy from four to five years now in her to breast cancer in metastatic So I think we are making actually lots of progress I hope that the immune therapy will will be part of it especially for triple negative breast cancer because we haven't made any progress there over the last few decades and that's where we really need Need to booster, but I think for most patients. That's true They are chronic illnesses Hi, good evening. Actually. I have two questions. I'll throw them out there quick and see what happens What work if any have you been doing in the area of controlling inflammation or curing that? and I know what most of this is directed to breast cancer, which I'm personally thankful to you for but For prostate cancer. Is there any relevance of immunotherapy after prostatectomy with a rising PSA? So Prostate cancer is not completely my field, but You know in prostate cancer to lag behind even worse than in breast cancer, but there are at least there is there is a vaccine approved in Prostate cancer. It's called Provence that extends survival for patients who have Metastatic disease. I think for the rising PSA question that is still It's a little unanswered question, but there are many new targets that are being tested in clinical trials So again, I would encourage Anyone you know to participate in trials, you know, I work very closely with my prostate colleague at NYU who is bringing in very interesting trials that that may target certain checkpoint molecules Yes, give me a second I will give you the David Wise like the wise old man. He's very young An Inflammation, you know, that's that's a that's a very hard one because inflammation is part of our living and you can't remove all inflammation It's helpful wound healing and many other things So there were many trials looking at Cox inhibitors or aspirin to to, you know, try to inhibit it, but I Haven't seen much success in this field yet I think that goes back to trying to understand what what is really happening, right because inflammation has a Lot of benefits to us that we need it So if we can find out which part of it it is that the tumors hijacking then That may be a way to design new trials that can better target that but it is true right now There's we are lacking the real targets. What is it in inflammation? That's bad And we think that the next is part of that equation this This not be your specialty, but I've been asking this question for quite a while when I've come here Chirogenics on a tumor Now we know how frostbite works. It just destroys the skin or whatever and there's no ill effects from it It the what has been frozen the cells just the body just absorbs them with no Parallel Bleeding or other things and I'm I still don't know why it's not a trial when a tumor is Obvious in the breast or any place else They don't go in with a small tube or whatever and just freeze it in the areas around it You have any thoughts on that? So it's not an approved kind of method for breast cancer treatment because the downside to cryotherapy Freezing the tumor is that you never get to see the tissue. You never get to evaluate if the margins are clear Which is what we rely on often in recommending radiation and so on But there are trials with combining actually cryotherapy with immunotherapy in breast cancer Before their standard surgery that that trial has been done at memorial And it's been published and actually the cryotherapy can induce an immune response to the cancer as well So but it's not yet mainstream. I think it will be you know pursued in clinical research But it has certainly some benefits to it Is this approach is this approach applicable to other cancers such as brain cancer? Which is I guess completely different type of cancer is compared to breast cancer We mean clinical research with the checkpoint drugs or immune therapy drugs Yeah, immune therapy with brain cancer gbm in particular. Yeah, I think it's still lagging behind In that field, but there are vaccine studies in in gbms that are somewhat promising Also great colleague at NYU Andrew cheese the head of that I would ask for trials Hi, so I was wondering about dormant cancer cells Do they have certain processes that allow them to stay alive for long periods of time and not potentially go through apoptosis I Think that that's a great question. So so there is a lot of active Research in that field at the moment. There's some data suggesting that something called autophagy The process where the cell is is partly eating itself to sustain it might be involved, but it's it's not clear yet I think the autophagy is gonna look promising in the end It's just a question about the process that you work through and that is there's much discussion about You're working from your research with mice and then to clinical trials with People and and then then the process through the FDA to get Approve approval for treatment much discussion about what take does it take too long to Should things be speeded up should approvals be click in your work Do you find the system in any way a difficulty or that it works just great? Yes and no I think some of this is has to take time So I think that the basic research must take the time where we really get the experiments, right? otherwise Sometimes you do you design the clinical trials wrong and so there's an example in my field where there were a group of of drugs called matrix metalloproteinase inhibitors and they were Studied in mice, but they were pushed to clinical trial and while the trials then came out showing negative results The mouse experiments essentially showed that they were giving to the wrong kind of patients So I think that was an example of being pushed too fast and then of course there's other examples where things go very slowly I think that is Often the case if you don't have the right collaborators if you don't know what to do with your with your research and mice Well, how do you take it to the next step? That has been I think challenging before but I think that there's more and more of these collaborations that we are having now where clinicians and and Basic scientists are talking already as the research is developing and thinking about how can we take it to to the clinic as fast as possible There's many frustrations running trials the regulatory system is very Rigid and requires many steps However, it does take time as Mikala said because you have to wait for survival data often Not to be blinded by early responses in small trials. So you do have to really do The due diligence to to make sure what gets really FDA approved is worth it but I also I think that in this country clinical research is not yet as Favorably viewed because in children's cancers for instance when you look at the children oncology group Which is the cooperative group on this country. They enroll about 90% of all the children in clinical trials 90% and in adults we have maybe 3% of patients who go into trial. So We're it takes time to make progress unfortunately and it would be so much more helpful and Faster if if the majority of patients join trials, but now there are certainly other efforts at At mining data from standard practice use of drugs To see if across the United States for those patients who don't enter trials if the current therapy Serve them well or not and finding outliers and especially good responders and see what what they have received So hopefully that will be the next wave with very Intelligent systems to extract medical data To help us guide in the clinic a bit more what which patients should get what chemotherapy because right now It's based on just the risks benefits discussion with each woman Please Please join me in thanking dr. Egg a blade and dr. Adams There is a coffee reception right outside in the lobby. Please enjoy. They'll be here too to continue to the discussion. Thank you