Blood Cancer Awareness Month

September 07, 2021

Information

September 5, 2021

Yale Cancer Center

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email: canceranswers@yale.edu

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00:00Funding for Yale Cancer Answers
00:02is provided by Smilow Cancer
00:04Hospital and AstraZeneca.
00:08Welcome to Yale Cancer Answers with
00:10your host doctor Anees Chagpar.
00:12Yale Cancer Answers features the
00:14latest information on cancer care by
00:17welcoming oncologists and specialists
00:18who are on the forefront of the
00:21battle to fight cancer. This week
00:22it's a conversation about multiple
00:24myeloma and other hematologic
00:26conditions with Doctor Terri Parker.
00:28Dr Parker is an assistant professor
00:30of medicine in hematology at
00:32the Yale School of Medicine,
00:33where Doctor Chagpar is a
00:36professor of surgical oncology.
00:39Terri, maybe we can start off by you
00:40telling us a little bit about
00:41yourself and about what you do.
00:43My specialty focuses on plasma cell
00:46neoplasms or plasma cell disorders.
00:48The most common of which is multiple
00:51myeloma, which is considered to
00:52be a haematological malignancy.
00:54So let's back up a little bit.
00:57What exactly is a plasma cell?
00:59A plasma cell is a
01:01type of white blood cell that
01:03is found in the bone marrow.
01:05It's derived from a B lymphocyte,
01:07which is another type of white
01:09blood cell again found in the bone marrow.
01:11Tell us about multiple
01:14myeloma and what exactly it is.
01:16I mean when we think about
01:18cancers of white blood cells,
01:20oftentimes we're thinking about leukemias
01:22lymphomas, is multiple myeloma
01:24a type of that,
01:26is it different? Tell us more.
01:29As stated, a multiple
01:31myeloma is considered to be a
01:33hematological malignancy and so
01:35that term encompasses leukemias,
01:37lymphomas, and plasma cell neoplasms,
01:40of which multiple myeloma is one.
01:42So in multiple myeloma the
01:44abnormal cell is a plasma cell
01:46and these plasma cells proliferate or
01:49increase in number in the bone marrow.
01:52It's really not known what causes
01:54the plasma cells to proliferate in
01:57the majority of individuals,
01:58and it's this proliferation that
02:00is defined as multiple myeloma.
02:08In general, blood cancers
02:11are pretty rare, right?
02:13If you look at multiple myeloma,
02:15it's currently the 14th most
02:17common cancer in the United States
02:19and it represents roughly 1.8%
02:21of all new cancers diagnosed
02:23so not as common as some of
02:25our solid tumors that we see.
02:26And where does it rank relative
02:29to leukemia and lymphoma?
02:31There's some leukemias
02:34that are more common and some that are rare,
02:36so probably somewhere in
02:38the middle, not to be too specific.
02:41And who gets
02:45these blood cell cancers?
02:47These hematologic malignancies.
02:49Are there certain risk factors that put
02:51people at risk for developing them?
02:54As I stated previously
02:57for multiple myeloma,
02:58for most people we don't really know
03:00why they developed the disease.
03:02However, there are some factors that may
03:04increase the risk of developing myeloma.
03:07One is age, so the majority of people
03:10are over the age of 50 at diagnosis.
03:13With the current median age of diagnosis
03:15here in the United States being 69,
03:18another risk factor is a precursor condition
03:21known as Monoclonal gammopathy of undetermined significance
03:24also known as MGUS.
03:30Tell us more about that.
03:32MGUS is considered to be a precursor condition
03:35and the individuals are asymptomatic and
03:38it's usually discovered when blood
03:41work is done for another complaint,
03:44sometimes it can be that a primary care
03:47physician notices that there's an increase
03:49in protein in a simple serum chemistry.
03:52So that's a blood test that's
03:54done for another reason.
03:55Sometimes this laboratory work is
03:57done for evaluation of other problems
04:00such as osteoporosis or neuropathies
04:03and then they get referred to a
04:06hematologist and have further evaluation
04:08that then reveals this precursor state.
04:11Those are pretty
04:15general risk factors in terms of age
04:18and MGUS for multiple myeloma.
04:20Are there risk factors for lymphoma
04:23and leukemia as well?
04:29In general, age again plays a
04:31factor as we do tend to see certain
04:34leukemias in older individuals.
04:36It again depends on the type of leukemia,
04:38as there are different types.
04:39Acute and chronic lymphoid versus
04:42myeloid. And other potential risks
04:46can include environmental exposures,
04:49so there have been studies looking
04:50at the link between radiation in
04:53addition to certain chemical exposures
04:55such as pesticides or Agent Orange.
04:58And so those increase your risk of
05:02leukemias and lymphomas, but not
05:04of multiple myeloma. Is that right?
05:06Multiple Myeloma as well,
05:08there have been studies
05:09specifically looking at Agent Orange
05:11and pesticides as well as radiation
05:14so you know pesticides is something that I
05:16think a lot of people kind of worry about.
05:19And you know, as we're heading into the fall,
05:22people are still using
05:23pesticides as they're trying to
05:25tend their lawn and do their gardening,
05:27get everything ready
05:29for the winter.
05:30Should people really be concerned about
05:33pesticides or are there particular
05:35pesticides that they should watch out
05:38for and others that might be safer?
05:41That's a good question and I don't
05:43have a specific answer for you
05:44and a lot of these are
05:47looked at and some of the common
05:49pesticides that people may use
05:51may have warnings on them most of
05:54the time people are usually safe
05:56because they're using the regular
05:58household pesticides or chemicals
05:59if you will and ventilated
06:02outdoor space and really
06:03have minimal exposure.
06:05I think that that's
06:07kind of good information to get across.
06:09Just because
06:10people can sometimes worry about
06:12these things, but
06:13it may be that it's really not as
06:16toxic as some people may think,
06:18unless you're in contact
06:21with them in large quantities.
06:24So now that we've talked
06:26about the risk factors,
06:27how do people present with
06:31these hematologic malignancies?
06:33For a solid tumor,
06:37tumors we often can find a lump,
06:39or we'll have some bleeding
06:42or will have some pain.
06:45Blood cells don't generally
06:46cause those things, do they?
06:51If we walk
06:53through each thing individually,
06:55for patients who have leukemia
06:58a lot of times they will present
07:00with abnormal blood counts.
07:02By that I mean an abnormal
07:03white blood cell count,
07:04hemoglobin or red cells or platelets,
07:07which are the cell that helps prevent
07:10you from bleeding or blood clots.
07:12Sometimes an individual will be diagnosed
07:15when they have a blood count done
07:17for another reason and it's picked
07:19up because there's an abnormality.
07:21Sometimes people present because these
07:24abnormalities lead to other symptoms.
07:26For example, if there's an
07:27alteration in a white blood cell
07:29count is specifically a lower
07:31white blood cell count,
07:32someone may develop more frequent or
07:36recurrent infections if the red cells or
07:38hemoglobin is low.
07:39That's also known as anemia,
07:41and patients can
07:43become more tired or fatigued,
07:45and if their platelet count
07:46is reduced they can present
07:48with bleeding or easy bruising,
07:50so sometimes these people present
07:52because they have other symptoms and
07:54then it's revealed that these symptoms
07:56are because of a low blood count.
07:59For individuals who have lymphomas,
08:01sometimes they will present with a
08:03large lymph node and so in that case
08:05they may have a lump or bump if you will
08:08that causes them to present to medical
08:11attention and then for multiple myeloma,
08:14which is what I specifically focus in,
08:16sometimes people will not have any
08:18symptoms and again it's picked
08:20up because blood work is done
08:22for another reason,
08:23like an elevated total protein on a serum
08:26chemistry which is a type of blood test.
08:29Other symptoms that individuals
08:30could have could again be anemia.
08:32If the plasma cells increase in the
08:34bone marrow to the point where they
08:37start crowding out the normal cells,
08:39plasma cells also produce high amounts
08:41of protein that can be seen in the
08:43blood that are cleared through the
08:45kidneys and could lead to renal
08:47dysfunction or failure in severe
08:49cases if it has not been recognized,
08:52and plasma cells also accumulate in the bone,
08:54that can lead to weakness of the
08:56bone and hence pain or fractures.
09:00And so it sounds like a lot of these are
09:03really picked up on basic blood tests
09:05that you have when you go to your doctor.
09:08So how frequently should you be
09:11having routine blood tests done?
09:13Especially if these things don't generally
09:14present with a lot of symptoms?
09:18There isn't currently
09:20screening that's recommended
09:22for multiple myeloma or MGUS
09:25which is the precursor condition.
09:27So typically we tell patients
09:30to follow the guidance from
09:31their primary care physician,
09:33meaning their blood work really depends
09:36on other medical problems.
09:38For example, if someone
09:39has a heart condition,
09:41diabetes or another medical issue,
09:43they're probably going to have blood
09:45work done more frequently because
09:47of monitoring of that condition and
09:49the medications that are needed.
09:54When you talk about these
09:57conditions being found in older patients,
10:00who are also the ones more likely
10:03to have other comorbidities that
10:05will require routine blood tests,
10:08I wonder how many people who are younger
10:11might be walking around completely
10:14asymptomatic but actually harboring
10:16one of these hematologic malignancies
10:20that have never been picked up simply
10:22because they've never had a blood test.
10:23Is that possible or do these things
10:26actually then progress to the
10:28point of being symptomatic?
10:30Again when you talk about
10:33hematologic malignancies
10:33that's a very broad topic and so
10:37everyone is very individualized.
10:40And so if we look at multiple
10:43myeloma for individuals with
10:44the precursor condition MGUS,
10:47they can be asymptomatic for years
10:49and for many patients
10:52it never progresses.
10:55For individuals who have a low risk
10:56MGUS we
11:00tell them that the risk of
11:02progression is roughly 1% per year.
11:03So there's a large majority of
11:06people who will never progress.
11:07If someone has multiple myeloma
11:09and it's left untreated,
11:11it will progress to the point where
11:13they may develop syptoms,
11:15what was discussed being
11:17anemia leading to fatigue, potential
11:20kidney damage, or bone damage,
11:23so those patients will progress and
11:25become symptomatic at some point,
11:27it's difficult to predict that
11:28rate of progression.
11:30And what about
11:32for lymphomas and leukemias?
11:35Are those also ones that
11:38will progress to symptoms?
11:40Or is it possible for them to
11:42be pretty asymptomatic until
11:43they actually end up having a
11:46test that that diagnosis it?
11:48Yeah, so for your acute leukemias,
11:51and even the majority of
11:53your chronic leukemias,
11:54they will often progress again,
11:56varying rates of progression to the point
11:59where people will become symptomatic.
12:00Similarly, if someone had an aggressive
12:03lymphoma or a high grade lymphoma,
12:05they would progress to the point of symptoms.
12:07It is possible for individuals
12:10who have a indolent or a slowly
12:12progressing lymphoma that they
12:14may have had it for several years
12:16before the point of progression.
12:18The other question that I had was
12:20you talk about one of the
12:23things that's often a trigger to
12:25finding diagnosis of these
12:29conditions as being anemia.
12:31And for example, in multiple myeloma,
12:34where the plasma cells kind
12:35of crowd out other cells,
12:36and so the red blood cell count goes down.
12:41Two questions,
12:42first question is oftentimes anemia,
12:44especially in older people,
12:46can be associated with other things, right?
12:50GI bleeds,
12:52losing blood from other sources,
12:55iron deficiency anemia.
12:56How do you really tell that this
12:59is from something like multiple
13:02myeloma versus other things?
13:05Yeah, that's a really good question,
13:08and as you mentioned,
13:09people who are older and even
13:11younger individuals can have
13:13anemia for a variety of reasons.
13:15So typically we will work up and
13:17do a basic anemia evaluation,
13:20which includes looking at
13:22things like iron deficiency,
13:23other nutritional deficiencies,
13:25vitamin B12, and folic acid to
13:27make sure we exclude kind of
13:30the most common and treatable
13:33reasons for anemia first and then
13:35when we really don't have a source,
13:37then we kind of go on to kind of that
13:39next level of evaluation that does
13:42include hematological disorders.
13:44Well, we're gonna need to take a
13:46short break for a medical minute,
13:48but when we get back we'll learn
13:50more about how to diagnose and treat
13:52these hematologic conditions with
13:54my guest doctor Terri Parker.
13:57Funding for Yale Cancer Answers comes
13:58from AstraZeneca, dedicated to
14:01advancing options and providing
14:02hope for people living with cancer.
14:05More information at
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14:14As smoking involves the potent drug
14:15Nicotine. Quitting smoking is a
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14:19especially for patients
14:21undergoing cancer treatment,
14:22as it's been shown to positively
14:25impact response to treatments and
14:26decrease the likelihood that patients
14:28will develop second malignancies
14:30and increase rates of survival.
14:32Tobacco treatment programs are
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14:37centers such as Yale Cancer Center
14:40and at Smilow Cancer Hospital.
14:42All treatment components are
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14:48line medications as well as
14:50smoking cessation counseling that
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14:54More information is available at Yale
14:56Cancer Center dot org. You're listening
14:58to Connecticut Public Radio.
15:01Welcome back to Yale Cancer Answers.
15:03This is doctor Anees Chagpar
15:05and I'm joined tonight by
15:07my guest doctor Terri Parker.
15:08We're talking about hematogic
15:10malignancies,
15:11and particularly Doctor Parker's
15:14specialty of multiple myeloma.
15:16Now, right before the break,
15:18Terri, you were saying that a lot of people
15:22are diagnosed with multiple myeloma when
15:25anemia is found on a routine blood test.
15:29And that
15:30the first step is oftentimes to
15:31rule out the things that are common,
15:35rule out iron deficiency,
15:38anemia and B12, and folic acid.
15:41And all of those good things.
15:42But ultimately,
15:43if all of those things are ruled out,
15:46how then does the diagnosis
15:48proceed for people actually to be
15:51found to have multiple myeloma?
15:53And so the first step is actually
15:55additional blood in urine studies,
15:57so we will do a battery of tests,
16:00specifically tests that are called a serum
16:03protein electrophoresis,
16:04which is a blood test that looks to
16:07see if there's an increase in abnormal
16:10or monoclonal protein in the blood.
16:12We do a similar test in the urine.
16:14We will test other specific things
16:17called an immunofixation electrophoresis,
16:19quantitative immunoglobulins,
16:20and serum free light chains.
16:23And we put together all of these blood
16:26test and urine studies to determine if
16:28there is a monoclonal protein present
16:31which is a protein that's being secreted
16:34by an abnormal plasma cell.
16:36And so if you find that,
16:39then that means that people have
16:42multiple myeloma?
16:44Not necessarily, as I mentioned earlier,
16:45we can see a monoclonal
16:48protein precursor conditions,
16:49and so we take a look at the whole picture.
16:52So we look at the amount
16:54of monoclonal protein.
16:55If the patient has any other
16:58systemic symptoms, such as anemia,
17:01renal kidney insufficiency,
17:04or bone pain,
17:06this is more consistent with what
17:08we would call a monoclonal gammopathy
17:11of undetermined significance,
17:13that would be considered low risk
17:14that we would just have to observe,
17:17or if there were a significant amount
17:19of protein or other symptoms that
17:22would make us go one step further,
17:24which would be a bone marrow biopsy,
17:26which is the definitive way to
17:29diagnose multiple myeloma.
17:31And so when somebody has a bone
17:34marrow biopsy what exactly does that
17:36tell you?
17:39The bone marrow
17:40biopsy itself tells us what is the actual
17:44percentage of abnormal plasma cells.
17:47So we're looking for these abnormal
17:49or monoclonal plasma cells.
17:51So kind of one type of plasma cell,
17:53and they need to be over
17:5610% in the bone marrow.
17:57So that's what we're looking for,
17:59and that is diagnostic of multiple myeloma.
18:02And then if you find that,
18:04what's the next step?
18:05Is there staging or do you
18:07go straight to treatment?
18:08How does that work?
18:10Then we have to make another determination
18:13so we have what we call smoldering
18:16Multiple myeloma, which are symptomatic
18:23so individuals who have smoldering multiple
18:25myeloma meet that strict cutoff of 10%
18:29involvement of bone marrow but
18:31are really otherwise asymptomatic,
18:33meaning they don't have anemia,
18:36they have preserved kidney function,
18:39their calcium levels are within normal range,
18:42they don't have any bone pains or what we
18:45call lytic lesions or holes in their bones,
18:48and so these people we would really observe.
18:50But they have a higher risk of
18:52progression to symptomatic multiple
18:54myeloma that would need treatment.
18:56Wait a minute, wait a minute.
18:57So how do these people with
19:00smoldering multiple myeloma
19:02present if they don't have anemia?
19:04They don't have any
19:06abnormal kidney function.
19:07How do you see them?
19:10Yeah, so a lot of times these individuals
19:13are referred because they had a blood
19:16test done and that was what we call
19:19a comprehensive metabolic panel that
19:21included a total protein and they
19:23were noted to have a total protein
19:25that was elevated and so their primary
19:28care physician picked up that the
19:30total protein was high and then sent
19:32them for further evaluation for an
19:34issue such as a monoclonal protein.
19:36So that's one way we often will see
19:38these individuals, another is that monoclonal
19:43gammopathy's and multiple myeloma can
19:46be associated with other medical problems,
19:48for example as serum protein electrophoresis,
19:52which is the blood tests that we do
19:54as part of the evaluation for myeloma
19:57is often done an evaluation for
20:00secondary causes for osteoporosis,
20:02so sometimes patients will have it done as
20:05a work up if they are have osteoporosis at
20:08a younger age.
20:11We also can see neuropathy,
20:13so that's kind of numbness and tingling
20:16in the extremities in patients who
20:18have come up with these as well and
20:20so sometimes a neurologist as part
20:21of a work up for other reasons for a
20:24patient to have a peripheral neuropathy
20:26will send these studies,
20:28so that's how a lot of these
20:30patients present to us
20:31if they don't have any other organ damage.
20:34So these people with smoldering
20:38multiple myeloma
20:40still could have symptoms, right?
20:42They could still have this
20:43peripheral neuropathy,
20:44or they could still have osteoporosis,
20:47but they just can't have the other
20:49things that you mentioned, right?
20:51The anemia, the kidney function,
20:53the lytic lesions of the bone?
20:55Do I have that right?
20:56Yeah, that's
20:57right. So they can't really have
20:59what we call this end organ damage.
21:01You know our classification between
21:03smoldering myeloma and myeloma
21:05has changed over the years,
21:08and we now also have a set of criteria
21:11that I call my myeloma defining
21:13events which don't have to be organ
21:15damage but just a kind of a significant
21:18amount of disease burden, and we will
21:21treat those individuals as myeloma,
21:22even if they don't have any of the other
21:25classic symptoms you just mentioned.
21:26So really, we're looking for a significant
21:29involvement of the bone marrow,
21:31and we classify that as over 60%
21:33involvement or a very significant
21:36serum free light chain burden.
21:38And for those individuals we will treat them
21:41as multiple myeloma,
21:42even if they don't have those classic
21:44end organ damage that we mentioned.
21:46What does treatment entail?
21:49Yeah, so treatment for a
21:51newly diagnosed patient is
21:54a combination of drugs.
21:57Typically what you would
21:58consider chemotherapy.
21:59So we often refer to it as frontline
22:02or induction chemotherapy,
22:04as we're trying to induce a response.
22:08The treatment typically consists
22:09of a combination of three
22:11or four drugs and the determination
22:14of how many drugs and which drugs
22:16are often based on a few different
22:19patient specific factors in addition
22:21to disease specific factors.
22:24And so when we talk
22:25about patient specific factors,
22:26we really look at a patient and ask
22:30the question, how well do we think
22:32this individual could tolerate the treatment?
22:35What is their fitness?
22:38We don't necessarily look at
22:40age but kind of the overall person.
22:43What are their other medical problems,
22:45their comorbidities?
22:46What medications are they taking?
22:50Do they have heart dysfunction
22:51at baseline?
22:52Do they already have a neuropathy
22:54that's pretty severe?
22:55And then we look at the myeloma itself,
22:59meaning for every bone marrow
23:01biopsy that we do,
23:02we also send a study called cytogenetics
23:05and that is the study of
23:07chromosomes within that plasma cell.
23:09So we're really looking to see
23:11if there is any rearrangements.
23:13Additions, deletions,
23:14breaks and by utilizing these
23:18cytogenetic testing,
23:19we determine if someone is considered
23:21high risk or standard risk and that
23:24influences which treatment we give.
23:27And so what is the difference
23:29between a high risk and a standard
23:32risk patient in terms of treatment?
23:34I mean is it more drugs?
23:35Is it more duration?
23:38Is it more toxic?
23:40Yeah, so it's not necessarily
23:41more drugs. Fortunately,
23:43in multiple myeloma most of our drugs
23:46are very targeted to the plasma cell,
23:49but it may just be a
23:51different type of drug.
23:52So it may consist of four
23:55drugs versus a 3 drug regimen.
23:58You know there's still a lot
24:00of research being done to see
24:02what is truly the best regimen
24:04for high risk individuals,
24:05and there's a lot of different
24:07opinions out there,
24:08but it's usually going to be
24:09a four or three drug regimen
24:11with potentially one difference
24:12in one of the medications.
24:15And as we think about
24:18multiple myeloma and how you treat it,
24:21it seems to me that
24:24part of this has to do with how advanced
24:27the myeloma is in terms of how much of
24:30the bone marrow is actually involved,
24:33whether there's end organ damage,
24:35health, how fit the patient is, and so on.
24:38All of which makes me wonder about
24:42how important it is to get to a doctor
24:46as soon as you have those symptoms,
24:47how important it is to come to
24:51get diagnosed early versus late?
24:53I mean certainly that's something
24:54we talk about in a lot of cancers,
24:57but it sounds like in multiple myeloma
24:59there's really no real screening tests.
25:02No recommendations for annual blood work,
25:04for example.
25:05So does that really play a role?
25:07Or does it not matter as much?
25:10Yeah, so in multiple myeloma
25:13as in a lot of the hematological
25:15malignancies
25:16we don't stage it as we do our
25:22solid tumors and
25:25we don't talk about metastasis and
25:27so really the amount of bone marrow
25:30involvement doesn't play a role in what
25:33we decide to do for upfront treatments.
25:37So our staging is really based
25:38on blood work and we
25:40will often treat someone who is
25:42say a stage one versus stage three,
25:45very similarly because we have very
25:47effective drugs in the first line setting.
25:50But obviously we would want
25:52to seek medical attention
25:53if you had any symptoms,
25:55because say you present with kidney
25:58dysfunction, renal failure that
26:00does limit some of the treatments
26:02that we could give up front.
26:05And obviously if you start to have bone pain,
26:07you want to seek medical attention
26:09because you wouldn't want to end
26:11up with a pathological fracture.
26:13So we do encourage people if
26:14they have any symptoms to really
26:17seek medical attention.
26:20And the sooner you are diagnosed,
26:22the potentially more treatment options
26:23you have and the better shape you
26:26will be in to tolerate treatment.
26:28The other thing that you mentioned,
26:30which I think is something that
26:32it's important that we pick up on,
26:33is that you said that the
26:35treatments now are very effective.
26:37So tell us a little bit about
26:39prognosis of patients who are
26:41treated with multiple myeloma.
26:43Fortunately we have keep
26:46moving our overall survival and
26:49the percent surviving at five
26:52years each year thanks to the
26:54development of newer treatments.
26:56And so it used to be,
26:59several years ago, say in 2005,
27:01if we were giving this talk,
27:03we would talk about an overall
27:05survival of two to five years
27:11and so more recently we say
27:13five to 10 years and we're now
27:15talking about potentially
27:17moving that to 10 to 15 years.
27:19If you look at the most recent
27:21data in the United States regarding
27:23the percentage of patients that
27:25are alive at five years,
27:27it's about just over 55%.
27:30So, very encouraging.
27:32That's really great, and I guess
27:34that leads me to my next question,
27:36which is what are the exciting
27:38advances that are going on in
27:40terms of multiple myeloma research.
27:42How are you and others trying to move
27:45the ball even further down the field?
27:48That's a great question.
27:49There is so much exciting research
27:51being done here at Yale and within
27:53the field of multiple myeloma.
27:55And really at all stages.
27:59Right now we often will refer to multiple myeloma
28:02as a cancer that is treatable
28:05but not curable.
28:07So we're currently looking at
28:08ways to improve that frontline
28:10therapy maintenance therapy,
28:12in individuals who have relapsed refractory.
28:16The most exciting things are
28:17probably the development of CAR T
28:19which recently gained FDA approval
28:21and in addition to looking at the
28:23biospecific antibodies which are
28:25currently in clinical trial.
28:28Doctor Terri Parker is an assistant
28:30professor of medicine and hematology
28:32at the Yale School of Medicine. If
28:34you have questions, the address is
28:36cancer answers at yale dot edu
28:39and past editions of the program are
28:41available in audio and written form at
28:44yalecancercenter.org.
28:44We hope you'll join us next week to
28:46learn more about the fight against
28:48cancer here on Connecticut Public
28:50radio funding for Yale Cancer
28:52Answers is provided by Smilow Cancer
28:54Hospital and AstraZeneca.